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FOR OFFICE USE: n APPLICATII014 AOR SANITATION PERMIT ------ - -- - --------:---- ----- '" ' (Complete in Triplicate) Permit No. - _------_--_---------- This Permit Expires 1 Year From Date Issued Date Issued -------------------- ------------ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County.Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _��l � ° -- ---------------------CENSUS TRACT --------------.__.-- Owner's Name �.l-'/4 �-i--- -- - - -------- -------------------- Ph4e ------------------------------------ g Address� �$A---Q �s - ------ City1i2� Contractor's Name ------------------- - --____--.License # v�-5y1.�.3__ Phone __yl°_ ________..-._-.-- Installation will server 5 ResidenceXApartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other ------------------ =-=6---------------------- Number of living units:_____:__ Number of bedrooms ---!-______Garbage Grinder ------------ Lot Size `�4Rt--- -----.----- Water Supply: Public System and name ------=-----------------------------------=---------------------------------------------------------------------Private' r Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay 10 Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type __________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �1 { NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i V i � PACKAGE TREATMENT [ I SEPTIC TANII` Size--` - 2-•_________-_ Liquid Depth ----y-__________,_--_- C; Capacity/p?h0_-__.__ Type 1k_ __ Material__ -- No. Compartments ____ _..._�_.___ Distance to nearest: Well - 4_________________________Foundation _l Q---__________ Prop. Line --�lr ►._ LEACHING LINE No. of Lines �-_- _/___________ length of a ch line___ �_Q__�-- --___ Total Length __/U.a_�_____--- •, 1. gy D' Box ------------ Type Filter Material `_ _ Q --Depth Filter Material _-___,�AV______________ ___ �_ i ' p Distance to nearest: Well - 4_____-______ Foundation -O _____________ Property Line _ ___._ .� SEEPAGE PIT [ ] Depth„_____________ � ___ Number _-_____ Rock Filled Yes No ' ---------._Diameter -------- - - --------- ❑ � WaterTable Depth ----------- - ----------- --------------------Rock Size -------------------------------- t Distance to nearest: Well ----------------------------------------- Foundation ----------------- -- Prop. Line _________----__...__ REPAIR/ADDITION(Prev. Sanitation Permit 5# ------------ - ----------------------- Date ___________________________------_) Septic Tank (Specify Requirements) ------------ • ` ---------------------------------------- --------------------------- ----------------------------------- Disposal Field (Specify Requirements) ________________ . '-� ' N � 4 {Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will bedonein accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the. San Joaquin'Local Health District. Home owner or licen- I sed agents signature certifies the following: i "I certify that in the performance of the work for which this permit is issued, ishall not employ any person in such manner h as to i bec es t o or an's Com sation laws of California." Signed Signed -------- ---- Owner L4�By ------------------------ i------ Title ---------------------------------- ---------------------------------- {lf other than owner) FOR DjkAitjMENT F ONLY APPLICATION ACCEPTED BY ---- ----------------- ---CA-- -- DATE 1�-7� -- BUILDING PERMIT ISSUED ------------------ --------------f-------------------------------------------------DATE ADDITIONALCOMMENTS --------------------------------------------------------------------------------------- ----------------------------------------------------------•----------- ------------------------------ ---------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- --------------- ------------ ---------------------- ------ Final -- -------- _ _ --------------------------- --v-- ---------- ----- ----- Final Inspection by- - -------------- G' ---------------------------------------------------------------------- ------Date - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, ' . 1-'68 Rev. 5M