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x `FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT ---------- ---------- •------------- ----- t 7 r �� (Complete in Triplicate) Permit No. _._ __._--__________-- _______________ This Permit Expires 1 Year From Date Issued Date Issued ___ -_7� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein . des1cribecIll This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -_._ _ -------- �, �-��,��---L�,l��,�----�.✓�_..__--CENSUS TRACT -------------- Owner's Name 0 --- -- ----------------------:-----------------,-------------------Phone _ Address -_„�-- ------7-/---- 13� ?�/�lr Zc�fr l----------------- City _E/C1��/ -= I -iContractor's Name ....f�,�r----� �{C--------- --------------------------License # �__ Phone f � , Installation will serve: Residence jZ Apartment House❑ Commercial :❑Trailer Court 0 Motel Ej Other _______-_- Number of living units:_.___-___ Number of bedrooms _______Garbage Grinder --/YL1-- Lot Size �' '_______ Water .___ Su - PPIY: Public System and name ______________ _ _ _- - ' v •- ------------------------------------------ ------------------=---------,-- Private t Character of soil to a depth of 3 feet: Sand'j� Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i 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.) � E NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) O r ;TREATMENT [ ] SEPTIC TANK,[ j Size-------•------------- ------ Liquid Depth --------------------- PACKAGE�' -- 6\ Capacity Type ---------- ------ Material------------:-------- No. Compartments -----•-• -------- Distance to nearest: Well -----------------------------------,Foundation ---------------------- Prop. Line -.-------------------- LEACHING' iLINE ... , [ 7 No. of Lines ------------- ------ 'Length of each line.----- ------ Total Length _----------_--_- j 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------...----------__________-___-_- SEEPAGE P t � , .. i t i # Distance to nearest: Well ____�_________________ Foundation .____-____.__ _______ Property Line I „IT [ j Depth ------------ ----- Diameter --------------- Number ----------- ---------- Rock Filled Yes '❑ No Water Table Depth ------------------------------------------------Rock Size --------------------------- Distance to nearest: Well ---- -----------------------------------Foundation -------------------- Prop. Line -------- ------------- REPAIR/APIDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date --------------.------------------_) Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- Disposal'; Field (Specify Requirements) ---------�fJ__;`--`, � ___ //j/� _______________ _ I I _# -------- ------------------------------ -----------------'! ------------- 4 � (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify th"at in the orm ce of the work for which this permit is issued, I shall not employ any person in such manner ) as to become subje o ma 's Compensation laws of California." Signed ------- - - --- ------------- Owner i BY -----:- ---- ----- -- --- - ---- - ------------------------------------------------------- Title - ------------------ f o an owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- - DATE g= � ---------------- --------------------------------------------- BUILDING PERMIT ISSUED ----------------- -------DATE ------- ------- ---- -- - - - ------------ ADDITiONA`L COMMENTS ------------------- - ------------------ --------------------•---- ---------------- -------------------------------------------- Final Inspection ------ ----------------------- -----------------------------------------------------•- ---------------- - ------------ ` --- -- ----- - ------------------ -- by - - - ---------------------------Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 �1-'68 Rev. 5M-