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R FOR C3f`..iZ,i: USE: --.__ APPLICATION FOR SANITATION PERMIT --------- 6 (Complete in Triplicate) Permit No. ----------•-- -------------------------------------------- ----------------- --------------------------------------- -------------------------------------------______________________________________________________-__ This Permit Expires 1 Year From Date Issued Date Issued .7_ 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 . l0 O _ .1V-------- ----------------------------------------CENSUS TRACT -------------------------- Owner's Name _.� 1V��---Z�- _04—I&V—� ��.-'�-----------------•-------------------Phone ----------•--------------------•---- Address1 1-' ----------------- ---------=------------------------------------------------- City ------------------------------------•-------- Contractor's Name --- ------------------------------------------------.License # Phone Installation will serve: Residence 2]-Apartment House-F] Commercial :❑Trailer Court ;❑ Motel ❑Other --------- ---------------------------------- Number of living units:__________ Number of bedrooms _ ------ Grinder __________ Lot Size /1�_ _ 7-61-0- - --------------------- Water Supply: Public System and name ----------------------------------------------------------------------------------------------•---------------Private [1�-- 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, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREAT ` INSTALLATION:_ )ENT [ ] SEPTIC TANK'[�� 5ize_, �d __9�__*�_______ ______ ______ Liquid Depth _f2�----_------------ Capacity Ca acit llzQQ 6_ T e MaterialG�00��ee No. Compartments Distance to nearest: Welf ---____________________Foundation ___-Foundation �7- Prop. Line __ ___-______ U � LEACHING LINE [�o. of Lines -----/_---------------- Length of each line-------- Total Length -----�'�.______.________ 'D' Box /VP --- Type Filter Material _10_C C--_Depth Filter Material _____/_ _r-__-.----------------....... Distance to nearest: Wel! '.__ Foundation _.__l_Q___ -_ __ Property Line _____________ _rrSEEPAGE PIT [4� Depth S r Diameter __ Number -------------/------ ----- Rock Filled Yes No C3 Water Table Depth --------,¢¢D_,�-------------------------- Rock Size -- -_3-Y-j -�'----------- Distance to nearest: Well ------e�Gf Q___--_________________Foundation ____ Prop. Line -.5----------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) ---- ---------------------------------------------------------------------------------------- -------------- -•...--------------------------- Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------------------------------------------------------ ------------- -------------=------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ f (Draw existing and required ad ----------------------- -- ------------------------------------- ------- --------------------------------------------------------------dition 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 Sane Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following- 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such mariner as to becomsub'` W rkman's Compensation laws of California," Signed --- ----- _ o ---------------------------------------------------------------- Owner BY ------ --- --------------------------- ------------------------------------------------------------- Title ------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- --------------- ------------------------------------------------ DATE '' - - -----•------••- BUILDING PERMIT ISSUED ----------------- ----------------------- --DATE - --- ------------- ------ -- -------- ----- ADDITIONAL COMMENTS -t ------------------------------------------------------ -------------------------- --------------------------------- --------------------------------------------------------------------------------------------------------------------------------- --------- ---------------------------------- - ------------------------------------------------------ ------------------------------------------------------ - --------- - - --------- --- - ---------------------------------------------------------------------------------- -- - - =------- FinalInspection by: --------- ------------- --------------------- --------------------- --------------------------.Date ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M