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1HAOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -73-435 ----- (Complete in TriplicatedPermit 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/LOA N `Z_f - ------ --- ----- --- - V_--/2 ---CENSUS TRACT ------------ ----•-------- Owner's Name -------- ----------- ------ � Phone --------------------•-•---••-------- Address �� LitY ---------------------------------------•-•- --•------ • Contractor's Name a.—, %- ------ ------- --- - --.License # Installation will serve: Residence ❑Apartment House❑ Commercial: Trailer Court ;❑ Motel ❑Other Number of living units:------/___ Number of bedrooms ____'1'-- ..Garbage Grinder ----------- Lot Size ------ . ------. Water Supply: Public System and name ------------------------------------------------------------------------------------------------------- ------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -C2� 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.) NEW INSTALLATION: (No septic tank or seep a pit permitted if ublic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ Size _ ------------- Liquid Depth __ ---_______...____-_ u P Material__ No. Compartments _- Capacity �--�'-� - TYPe - -------- - - - P �---......---- Distance to neatest: Welt ___________–�� Foundation -------- _-_ ____ Prop. Line --- I __ ---- ----- LEACHING LINE [ ]�No. of Lines ----------------------- Length o each line------- _. _____ otal Length ,--1.8Q, 'D' Box _r`----- Type Filter Material _-__6_EJ,__Depth Filter Material ____ _______________________ ______ Distance to nearest: Well --------.-d ` __:= Foundation Property Line ------- -Fil46r- led p /epth Rock Filled Yes No �i_ Depth ------ - __-- .�-- Number _�—r ,--/--� Water Table -____---- �O _______ _ ________Rock Size -l/ -X-_- •�_____ Distance to nearest: Well ______________ ---------Foundation --_ -- _ _ Prop. Line IJ REPAIR/ADDITION(Prev. Sanitation Permit# .------..__--------------------------------- Date ----___________-___-__.__________} SepticTank (Specify Requirements) -------- ----j-------------------------------------------------------------------•---------------------------•- ------ ------------------- DisposalField {Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------I------------------•------ --------------------- ---------- ------ ---- -------------- --- ----------------------- -- -----------------------------------------------•------------- (Draw existing and required addition on reverse side) I hereby certify that I 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 that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Wo a Compensation Iows.9f California." Signed ------- ----------------- ----------- ------ ---- -- =----- � --- - -f---------- Owner 6 ---- ------- ------------------------ By --------------------------- '!�� - '�_ Title (If othe an owner) FOR DEpAitTMENT USE ONLY APPLICATION ACCEPTED By ----- ----------------------------------------------- -----. DATE ---- -------- BUILDING;PERMIT ISSUED ------------------------ -- --DATE --------------------- --------------------- ADDITIONAL-COMMENTS--------------------------------------------------------------------------- -------------------------------------------------------------------------- _ _ -- -- --- ------ -� �------------ -- --�z�' Final Inspection by., - Date -----'� - T SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M.