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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------�..---------...--.. _ . Permit No. ...��.::..��..�.r� ............................................ {Complete in Triplicate) This Permit Expires 1 Year From Date Issued bate Issued ... Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work herein describer!. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION CENSUS TRACT Owner's Name ... p V...; � .......Pho Address , . ......... V...E-�� 7 City zu a ............ ...................... -------- -------- -1:- .. n Contractor's Name ti� .,5 !?..c.License # , ..-- Phone ...................•.-.-...-.- Installation will serve: Residen ❑Apartment House 0 Commercial❑Trailer Court C) Motel ❑Other _ . :_ C\ Number of living units ............ Number of bedrooms Garbage der .......... Lot Size ......._ ................................... Water Supply: Public System and name ................6 - -- .................. .............................Private ❑ Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loom Q 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 an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK f } Size................................................ Liquid Depth ..........................� Capacity -----•----- Type -------------------- Material---------------------- No. Compartments ...................... • Distance. to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE { ] No. of Lines .................... Length of each line............................. Total Length .-.......................... 'D' Box ............ Type Filter Material ....................Depth Filter Material ..... ...................................... Distance to nearest: Well ................... Foundation ........................ Property Line ........................ SEEPAGE PIT { ] Depth -------------------- Diameter ---------------- Number -------------- ........ Rock Filled Yes ❑ No ❑ Water Table Depth -•..............................................Rock Size .............. Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ---.----.---....---------------------------- Date -_--_._.--._....................._) Septic Tank {Specify Requirements) ------------------- .............................--............ ............ Disposal Field (Specify Requirements) e �, —4 _ a 6LV ~ - --- -............... ....................----------..................................................•..---- _______ (Draw existing and required addition on reverse side) 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. Hoose owner or licen- sed agents signature certifies the following: N certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -----------------------•-- --------- Owner By ------•------------------------ ---------------------------- ----------- - ------- - ------------------ - -•------- - itle -- -- - ��.' (If other than owner} �'FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- - � -. .. DATE -S. . z -17-(...... -------------------------•--- - BUILDING PERMIT ISSUED ------ --------- ............. ---..-...._ ---------DATE .... .................. ................... ADDITIONAL COMMENTS ..----..----•------------- _.._._ . ---- ---------------------.------------------------------------------------------------------------- ...... ...-.-..--------- •, --• ------ -•-- -- ---- Final Inspection by: . . -------------- Date f.-Z. .. - EH 13 2 `6 v• SAN JOA QUIN LOCAL HEALTH DISTRICT 8/74 3M