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..`R OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- -------------------- Permit No.x12 . �... (Complete in Triplicate) - Date Issued ---- __-__----------------- ------ This permit Expires 1 Year From 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 County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION/__ �1 A�.� �� .,------------CENSUS TRACT :�---- --- -------= Owner's Name /9+YL+cj` �G - r � = Phone 3 ----------------------- ------------------- � U 4 ---------- -- ------------ Address �� -=---- r. y --------------------------------------- City,"-; �� ,----------------------------- --------------.--- Contractor's Name __. ---- '-----------------------------------------------------------------License # ------- - -------------- Phone ------------------------------ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer-Gedrt I Motel ❑Other ------------------------------------------- Number of living units ___---- Number of bedrooms _r; ------- Grinder _.__---..__. Lot Size �'��` ------------�t-__--------- 01 r Water Supply: Public System and name -------------------------------f--------------- -------------- ------------------------------------------------Private. ] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .0 Clay.Loam.❑ Hardpan ❑ Adobe❑ Fill Material ------------ If yes, type---------------------------- (Plot ___________________(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) , l NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) En3 PACKAGE TREATMENT [ ] SEPTIC TANK:[] Size/(�t-- --------------___-------- Liquid Depth __ ------_------ -- 16 Capacity/-3- 1?---------- Typd-,�" ------ Material------ ' No. Compartments ' ------------- Distance ---------=Distance to nearest: Well -________-__________Foundation __�°-------------- Prop. Line -_ �_ _._..__.. LEACHING LINE f" Na. of Lines ----/__________._.__ Length of each line-----/�A_______________ Total Length .Z�------------------ 'D' .___._-. _. -_. .'D' Box ------------ Type Filter Material Al?----------Depth Filter Material ------------------................... r Distance to nearest: Well _lq-_ -4......... Foundation _f `_f------------- Property Line________________ SEEPAGE PIT Depth A-47------------ Diameter 33_`________ Number ___----._______.___-_____- Rock Filled Yes. ) No IQ - r Water Table Depth --f' ---------------------------- Rock Siz -:'------- J t.f+ r Distance to nearest: Well __'! _�__ _______ __________ ___Foundation _�____--- ______ Prop. Line ti..._____------_--.._. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I SepticTank (Specify Requirements) ---------- ------------------------------------------------------------------ -------------------------------z.---------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------- ----------- =-----------------:- ----------------------------------------- - �- --------- ---------------------------------------------------------------------------- Draw existingand required addition-an.reverse side),,,,:, I hereby-Ciirfify'thcW 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 beco ublect to Work s Compensation laws of California." Signed . -------------- Owner By ---------------------------------------- --------------- Title ------------------------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _/'��`�.�-y,- �*�- ----------------------------------------- --------------------- -- DATE✓= o_.Ta-- ------------- BUILDING -----------BUILDING PERMIT ISSUED --------------------------------------------------------------------------------------------------- ------DATE -------------------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------- --------------------------- ----------------------------------------------------------------------------------------------------- - ------------------------------------------------- --------------------------------------- -------------------------------------------------------------------------- ------ ------------------------------ -- -- 7------------------------------------------------------------------------------------------------------ ------- - - ---------- Date ----------- Final inspection b ------------------------•---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'S8 Rev' 5M.