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f FOR OFFICE�U S ----------- E: - APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. 's- _____. 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 ount Ordinance No. 549 and existin Rul`e� a d RRegulaationsk -�*;1-- JOB ADDRESS/LOCATION ____IQs ' (Q_ o-___! _ _ _ _[_��' ._ ---------------------CtNSUS TRACT Owner's Name` U,,44: � / �---- -�.`� Phone�� Address ----- -- � 0 /Cc- .`� -- City ----V,4- ------- Contractor's Name __________<a:.>- t_`rt__•41-e - ---- -- -License #/"or/�_____ Phone Installation will serve: Residence XApartment House-[] Commercial ❑Trailer Court ;❑ Motel ❑ Other ----------------------------------------__ Number of living units:----I------ Number of bedrooms _____Garbage Grinder - ---------- Lot Size �Priivate%, _________________ Water Supply: Public System and name ----------------------------------------------------------------------------------- -------- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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'f�iC.t,.4: f Size------------------------------------------------ Liquid Depth ____________--___-_-----_- Capacity -------------------- Type --------------- Material--------------------- No. Compartments ...................... Distance to' nearest: Well _Foundation ______________________ Prop. Line ___.-------------______- LEACHING LINE (Ao. of Lines ________________________ Length of each line---------------------------- Total length ------�'"�.__._- _ \ D' Box ------------ Ty�e Filter Material __________________Depth Filter Material Z Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _________________t._.___ SEEPAGE PIT [ ] Depth _________________ Diameter ________________ Number --------------------------- Rock Filled Yes ❑ No 13 Water Table Depth --------------------------- -------------------Rock Size ------------------------- ------ ---DiDistance stance to nearest: Well ________________________________________Foundation -------------------- Prop. Line .........._........... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ___--------------__._____ _ _ ____ _ ___ Disposal Field (Specif Requirements) � �"`'� ------ -- ^ ----- °' �- ----------- --------------------------------- ------------- --------- ------------- (Draw existing and required addition on reverse side) .I hcieby 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: ti "I certify tht the performan of the rk for which this permit is issued, I shall not employ any person in such manner as to b!522e s jVt W r n's am sation laws of California." Signed - --- - --- -- --- ------ BY ------------------------------------------ ---- Title' -- -- --------------------------------------"----- "h (if other than owner) _ FOR EPAIRTMENT USE ONLY APPLICATION ACCEPTED 'BY ti -'----------------------------- -------- DATE ��"tom. BUILDING PERMIT ISSUED -- ------- ---=----------- -- ---- - - --------------DATE ----------------------------------------- ADDi7lONAL .COMMENTS --- ----------- - --------- --------------- , -- --------------------=------- -- ---------------------------------------- -----------------------------------------------------------------------�r--_-_ -- --- ------------------------------------- --- ------ ------ -------------------------- ----------------------------- Final Ins ecti Date ____ -------- SAN - -- -- - JOAQUUN LOCAL HEALTH DISTRICT { E'H. 9 1-'68 Rev. 5M