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r , FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 3 Permit No: ------------ -------------------------------------- ---------- -.�--- (Complete in Triplicate) ----- - ---------------------- ---- - Date Issued x'/23 This Permit Expires 1 Year From Date 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 Ordinance No. 549 and existing Rules and Regulations: d -�0s.CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION .__-_ - ------------------------ ----------- s� Owner's Name <� ----------- Phone f�,�_r Q Address _ -------z ��- dt'VA-cc44 a -Pt---- _,;;>v F-�- ------------------------ City ----------------------------------- ------ Contractor's Name _.-_ -- ---- ��-License #��a- �- -Fr - Phone t Installation will serve: Residence;Apartment House❑ Commercial _]Trailer Court ',❑ Motel ❑Other ------------r------------------------------- i +� _Garba Number of living units:__._---- Number of be rooms ge Grinder ___ Lot Size ____ - --- Water Supply: Public System and name ----- --�!1�--f "[:------------- --------------------------------------.----Private { El Character of soil to a depth of 3 feet: Sand'o Silt❑ Gay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ AdobeA Fill Material ------------ If yes, type ---------------------------- (Plotp Ion, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r lQ -� PACKAGE TREATMENT { ] SEPTIC TANK'' Size___ ___.----_ ``'------------- Liquid Depth ...S Capacity �t yp / Material-AfdpnNo. Compartments ____A-,r__...__:.._. w Distance to nearest: Well ....-� Foundation -__�_-_ .......... Prop. Line _.---_____----_____ p LEACHING LINE No. of Lines -----.Z------------- Length of each line-----Zd-!q�... ----- Total Length •---------- p 'D' Box ---_�.__. Type Filter Material _ 4V-4___Depth Filter Material -__---1-� -- -------------- Distance to nearest: Well --__ _ _ ------- Foundation1D:'---_-___---_ Property Line ---S~--___---. --. F SEEPAGE PIT Depth ----oZS ._____ Diameter _ ______ Number ________________________ __ Rock Filled Yes �' No ❑ G -Rock Size ------ -- -r------- ----- Water Table Depth -------�-- Distance to nearest: Well ----Ine_____________________Foundation _1�---�---- Prop. Line ..�-.•-----.•------ i REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- Septic Tank (Specify Requirements) ----- -- ---------------------------- -------- -----------•--------------•------------- t� Disposal Field (Specify Requirements) ----------_--------------------------------------------------------------------------------------------------------------'----------- I -----------------------------------------=-------- --------------- Y . - .---_--__ ___- _,_ _ _ __ ------------------------------------------------------- ___ _ ___________________-_________________._______________.._________..___________.__._____. -- __- - - _ --_________ (Draw existi_ __ng and required addition on reverse side) I 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------- ------------------------- Owner --------------- Title [If other than owner) _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------- DATE --' `_%� ---------------------- BUILDING PERMIT ISSUED ----------------------- -------DATE ------------- ----------------------------- ADDITIONAL COMMENTS --------- _____ __ ---- -- - - -- ------------------------ ---------------------------------------------------------------------------------------------------- ----------------------------- �r�-ate - - - --------- -- --- --- -- ---- ---- -- ------=------- --inal------------ion ------ - - -------Date -- -------------- Final Inspection by. --- - �� --- ---------------- ---- --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M