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FOR OFFICE USE: ' ""' APPLICATION FOR SANITATION PERMIT C17 --------------- -- ------------------------- ---- .7-1- ° '•7 (Complete in Triplicate) Permit No. -- ----------------------------- This Permit Expires 1 Year From Date Issued Rate 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 Or ina7c"o. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ` 3 ' � �7 -' - p r--------.---J_/----------- - ---_-____CENSUS TRACT __. P�Owner's Name �C»Y- ''� = = -Phone Address --------------------'---------------------------------- ------------------------------------------------- City n/,__,/ e,-,Z-------------------------------------------- --------- Contractor's Name -------------------------- ------License # ------ - -------------- Phone ---------------------- ------- Installation will serve: Residence partment House❑ Commercial ❑Trailer Court Motel ❑Other .------------------------------------------- Number of living units:-./-------- Number of bedrooms _�T-------Garbage Grinder -'-"______ Lot Size��`2�J --------- Water Supply: Public System and name ---------------- ----------------------------------------------------------------------------------- s---- - Private © Character of soil to a depth of 3 feet: Sand' iIt❑ 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.) L/► NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,) SEPTIC TANK' Size------------------------------------------------ Liquid Depth -----�a1��2-.-- ----- 4 PACKAGE TREATMENT [ ] [ `/ _ Capacity 1'�a'19________ TypeG+ '�/-------- Material P____ No. Compartments _ ------ .......... - Distance to nearest: Well I ____________________________Foundation � __:_.__-______ Prop. Line _ ....______________ rj/ - Total Length LEACHING LINE [►�No. of Lines ------------------ Length of each line------- ` --01 ----------------------- 'D' Boxy------- Type Filter Material _ ----Depth Filter Material ------141------------_________________ __ Distance to nearest: Well __A:� -______-_-__ Foundation _0________________ Property Line ------------- --------- _ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number _-_`_------------------------ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size --------------------•-- -------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION{Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------•------} Septic Tank (Specify Requirements) --------------------------- ------------------- -------------------------------------------------- ` DisposalField {Specify Requirements) ---------------------- -------------------------------------------------- -----------------------------------------------•----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- ------------------- -------------------------------------------------------------------------------------------------------- (Draw existing and required addition 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 San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the perfo once of the work for which this permit is issued, I shall not employ any person in such manner as to be me subject to orkiran's ompensation laws of California." Signed - . . - -------------- ---- ---------------------•--------------- ----------- Owner BY ----- ------ -- ----------------------------------- ------------------------------ Title -------- ---------- ------------- ------------ -------------------- --- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .._ __._ .. --------------------------------------------------------------- �3--�-------------- -- --�-- DATE __�/�----------- � - - BUILDINGPERMIT ISSUED ---------------------- ---- - -----------------------------------------DATE ------------------------------- ----------- ADDITIONALCOMMENTS ------F�-(1_. ��%i' v"el�---------- -----------•------------- ------------------------------------------------------------ •---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ----------------------- --------------- FinalInspection by: ------------- ------------------------ --, ------------------------------------------------------------Date ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M