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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ----------------------------------------------- (Complete in Triplicate) Date Issued .�`.��--' This Permit Expires l Year From Date Issued -------- ---47A- ------ --------------- 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/LOCATIO CENSUS TRACT �----�---.•-.-----� i �i --------=--------- ---- Owner's ame 5 --Q - ___Phone -. Address ---�--� -----• City - - �-- �-'�--1-�-4�--- ---------------•--- -------- T Contractor's Name ��- ` License # ------ Phone Q L t Installation will serve: Residence partment House Commercial ❑Trailer Court ❑ i Mo el 710 Other -------------------------------------------- rooms --------------------------------------- -- r ' Number of living units:_________ Number of bedrooms -_.._Garbage Grinder __. -___-- Lot Size 4 . t nn. Water Supply: Public System acid name ---(.�_-__w_r-----'- Private ❑ Character of soil to a depth'of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam { Hardpan ❑ Adobe-❑ Fill Material ------------ If yes,type----------------------------- ! (Plot plan, showing size of.lot, locationofsystem in relation to wells, buildings,_ etc. must be placed on reverse side) s NEW INSTALLATION:: (No septic tank or seepage pit permitted if p#ic se9wer is available within 200 feet,) i J PACKAGE TREATMENT [ SEPTIC TANK Size---3e.5- I_c - .------. Liquid Depth ____-- ------- Capacity Compartments Capacity � C4'3 Type Material--_ Ji- t ----.-Foundation __ _ Pro Line ---------------------- Distance to ne est: Well --- - --_-_--- P• .1 f a r l --- ' LEACHING LINE • [ ] {�•-No. of Lines ------�-- ------ Length of each line___._ Q--_a---=•---- -- Total Lengt1/.cam- { 'D; Box ___ _.__ Type Filter Material _?ocj ----Depth Filter Material ____j ------------- -=------------ f r -� i Distance to nearest: Well -. � ------- Foundation ___1 __ _____ Property Line __._____...-.----.._-_-- SEEPAGE PIT [ Depth _ ------- Diameter-------•-----_.___Number..--= :-------------- Rock Filled Yes ❑ No .❑ — - i Water Table Depth [ ` ---------------Rock Size -------------------------------- Distance ------------------------- --Distance to nearest: Well ---------------------------------------Foundation -----:---------.---- Prop._ Line __..------------. --- REPAIR/ADDITION(Prev. Sanitation Permit# -------�=--Y------------------------------ Date .______-___.------:.--------------) Septic Tank (Specify Requirements) --------=---------------------- - ---------:------------- •.r--•------------------------- - - ----------------------------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------------- ----------------------------------:-------------------------------- -------- .. _______ -------------------------------------------------------------------------------------------------------------------------------------- L (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 ploy any person in such manner as to become subject Ito Workman's Compensation laws of California." Signed,----------------- ------------ ---------------------------------- --------------- _: Owner ------------------------------ (If other than7it e owner) _ ,, ._� ., j ` FOR DEPARTS NT•USE ONLY APPLICATION ACCEPTED.BY --------- ----- -� DATE __ . ... BUILQING PERMIT ISSUED ` ------- DATE ------------------- ----------------------------------------- -- - — _ ... _..s_ -.-_- ....-- .. --.-Y ADDITIONAL COMMENTS �------------- ----=-------------------------- _- - --------- '�---------------------- `-=---------------------------------- ------------------------------------------------------- ---------------- , -- - - -- ------- - - . : x------------------------------------ ----------- --------------------------------------- ----------- _ ------------ --------------------------------------------------------------- --------------------------------------- Fina! Inspection b ---------------------Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1-'68 Rev..5M .