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FOR`O' FFICE USE: 3U- APPLICATION FOR SANITATION PERMIT k"-N' - (Complete in Triplicate) Permit No. -------------------- Date Issued -9."-�..---7-- --------------------------------------------------- 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 ounty Ordinanc No 549 and existing Rules and Regulations. JOB ADDRESS/LO , CENSUS TRACT --------------------- _------- - ---- -----Phone ----------------------------•--•--•- i Owners Name s _� /- Address . . � _ J City i �=G Contractor's Name ' pe, Phone1� . . � Li # �4- Installation will serve: Residence [?J Apartment House-E] Commercial ❑Trailer Court ',❑ Motel ❑ Other -----=--------- ---------------------------- Number of living units-------t-1 Number of bedrooms( ___G rbage1� ---------- rinder,. .j_. Lot Size �� _____._..-.. Water Supply: Public System and name ---------------------- ---- �1 �-----.- � •------------..Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cla ❑ Peat❑ Sandy Loam ❑ Clay Loam 'E] Hardpan ❑ Adobe ill 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 tanksor seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT •[ ] SEPTIC TANK . ize--.--- �- �-- Liquid Depth ---. ..:. ..._.._. ¢� Capacity -- r' --------- Type PM_ao,� Material_ �`_�_C-1 o. Compartments ----_----..--•--- --� Distance to nearest: Well -__ _--'_.__._....._Foundation ..-f _f_-__.. Prop. Line _ / --------- LEACHING LINE [� No. of Lines g of each lire--- �_. `_.4 Total Length 7f r.... D' Box l"- _��-. Type Filter Material _ __,_ _ . _ Len th t/ ^� ' � yp 1.1L��._._..�epth Filter Material .. ��_- Distance t nearest: Well _______________________ Foundation _ __`---------- Property Line-------------------_- SEEPAGE ..-.__.-..._..---- _- SEEPAGE PIT Depth r�..,_srr--_._.. Diameter ._. Number -.__ ---------------- Rock Filled Yes [4,- No tJ] Water Table Depth -------- / L Y ------ -----Rock Size --��-- ---~�------ Distance to nearest: Well ..._......_�-.................Foundation ...�ft� ..�..._. Prop. Line . _._._..__..._.. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------- .....................---) SepticTank (Specify Requirements) -------------------------------------- ---------------------------------------------•----------------------•-----•--------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------- •--------------- ----------------------------------------------------------------------------------------- -----------i----------------------------------------------------------------------------=------------------------ .................................................................... (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: "1 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 ------------------------- ------ -------------- 4---------------------------- Owner J B � ' ----- Title .! •yr ----- ---- -------------•----------------------- (If other than owner) . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------------- DATED'7 ----------- BUILDING PERMIT ISSUED ------ - ----------------------------------------------- --------------DATE -------------•----------------------------- ADDITIONAL COMMENTS ------------------------- ----------------------------------------------- -------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- - - - Q-U---------------------------- ----------------------------------------�- ---------- -'-- --- --------- --------------------------------------- ------------ ------ --- -- t _ �1Final Inspection by: i - Date - r SAN JOAINOCAL HEALTH DISTRICT vc� E. H. 9 1-'68 Rev. 5M y