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M�ArOR OFFICE USE: d•�'�L_? i, APPLICATION FOR SANITATION PERMIT ----------------------------------------------------- (Complete in Triplicate) Permit No. ------------------------------Y't_'�-->--�-'-"----- .�" --_----------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application.is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: T JOB ADDRESS/LOCATION ar ��t-__ - t----- - - -------- --------- -- 'CENSUS TRACT - Owner's Name _-- /54r/ - C'C ,�/ ------ -----------------Phone ---- `.- . /� ----- --- Address ---------- 1 S� .f10-f .ti/�[ �J --- ----- City. -� �----- Contractor's Name License # PhonezL'? QQ € Installation will serve. esidence ❑Apartment House❑ Commercial)Trailer Court 0 Motel ❑Other --------------------------------------------\ E Number of living units: Number of bedrooms _----------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 ❑ Clay Loam Hardpan ❑ Adobex 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.) a NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �r ti PACKAGE TREATMENT [ I SEPTIC TANK f I Size------1_�_ _ ___`�-------- Liquid Depth ..._ �_-..-_.._-- Capacity _�1Z40----- Type2s- Material__ No. Compartments --_-- ..... r I Distance to nearest: Well ----/-69D-'f-----------------Foundation _Z40-fe -_____ Prop. Line ----- .___---_-- y 1 f LEACHING LINE [ ] No. of Lines -----1--------------_ Length of each line----4Q-------.---_-_ Total Length ____ _Q----..-..---- 'D' Box -- Type Filter Material _A_ _�-__Depth Filter Material __Ar_____________ __r_._..-.-_-- r � Distance to nearest: Well ---16-6-_--_-___- Foundation ___� ------------- Property Line _�-__--___._-..._. �r i SEEPAGE PIT [ ] Depth -----� ----- Diameter _ �_-___ Number ---------- _-_-_-__---_ Rock Filled Yes No Water Table Depth __46-C--------------------------------Rock Size _- —,P- c-� La Distance to nearest: Well ------/RC2 -----------------Foundation ---l 200 Q__--__-__- Prop. Line .. ----------- REPAIR/ADDITION(Prev. Sanitation Permit># -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- DisposalField (Specify Requirements) ---------------------- ------------------------------------------------=------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------=----------------...---------------------------------------'------------------------- Y - - - - - - ---- -------- ---_- ----------------------- - (Draw-existing-and_ _ __require• d-addition on reverse sideI 1 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 becom ct to Workman's Com nsation laws of California." Signed - --- ------- ------- Owner By --- ----------------------- -,.�- - ----- ------- Title ...C-, (If other tha owner) FOR .DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY -------- ----- DATE --- -�'- ----------_----• --- /..---------------------------------------- BUILDING PERMIT ISSUED -----------------______-___ _ - ---------------------------------------- -- -------DATE ------------------------------------------- ADDITIONAL - --------------ADDITIONAL COMMENTS --------------------------------------------------------------- ---------------------.------------------------------------------------------------------ ------ ----- ------------------------------------------------ -- ----_--------------------------------------------------------- ------------ ----------------�------�--- --------------- -------------------------------------------- ---- ;1_.__5 - - ------------------------------------------------------ - ------ ------- Final fns ection'b ---- Date SAN JOA IN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M t