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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT W -5/0 ---------- ------------------------------------------ c Permit No- - - '- (Complete in Triplicate) - - - - --------------------------------------------------------- \0 This Permit Expires 1 Year From Date Issued Date Issued _�_�_�1____u 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 .__ ,P_ z--______ __________4eAmfc--)� _____e:_____________CENSUS TRACT __________________________ Owner's Name --------------,-j / 4 -----�----- S al.[----------------- [� ---------Phone `j---f/•O, Address - fOsR - 57" t___ y ----- --=t---f&+X d-------------- Contractor's Name ---------------------------- --------------------------------License # -- -------------------- Phone '' Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------=------- ---------------------------- Number of living units:__________ Number of bedrooms -3-------Garbage Grinder -�--- Lot Size -------� ---______________ Water Supply: Public System and name ---------------------------------•--------------------------------•-•------------------------------------------Private% Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam K 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 seepage pit permitted if public sewer is available within 200 feet,) (� PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size______________________________________________ Liquid Depth ------------•.._-___,____ Capacity -------------------- Type -------------------- Material--- ---- No. Compartments ...................... 1 Distance to nearest: Well _________________________Foundation ______________________ Prop. Line ...................... LEACHING LINE [ ] No. of Lines .----------------------- Length of each line__________________________ Total Length ------------________________ 'D' Box __________ Type Filter Material ____________________Depth Filter Material _-________________•________________.____-_ Distance to nearest: Well ______________________ Foundation _______________________ Property Line _________.________...... SEEPAGE PIT [ ] Depth --______ --------- Diameter ______________ Number ----------------_----------- Rock Filled Yes ❑ No Water Table Depth---------------------------------- •-_---------Rock Size ---------------------------•--•- Distance to nearest: Well _______________________________________Foundation ____ --------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ___----------------------------------------- Date _____________-____________________) Septic Tank (Specify Requirements) --`----`-------------------------` ---------------- Disposal Field jSpecify Requi menT) ----- C}Q_____________ P_Q._______ - '-_______________ -- --------- telFi ,�if�(� ----------`1'. -��'�'-r-""'` - _ --------- -- --•----- ------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- (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 i performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco,p4_yr6ject to Workm om nJ California." Signe ---- -- --- - -- - -- - -----------------------•-------------------- Owner -------------------- -------------------------------- Title ----------------------------------------------- (if - - (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ---- ------ ---------- - DATE 7 ala — BUILDING PERMIT ISSUED ..... - --- ----------------------------------------------------------------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------------•---------------------- --------------------------•--------------------------------------------------------------- ------------------- ------------------- ------------------ ---------------------------- - -------- ---------------- ----------------------------••------------------- ----------------------------- - ---- -- -- - - =tALTH ----------------------------------------------------- - - --- - Final Inspection by - Date -` � SAN JOAQ DISTRICT E. H. 9 1-'68 Rev. 5M