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- FOR OFFICE USE: -,o , _:. APPLICATION FOR SANITATION PERMITPermitNo. - ----------------- --------------------------- (Complete in Triplicate) This Permit Expires 1 Year From Date issued 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 -..-,CENSUS TRACT y� -------------------------- Owner'.s Name __ fq� y ---------------------------------------------------------------------- ---------------Phone ------------------------------------ Address --------- ----- --- /-- �< ------------ City -------- -------------------------------------------_------- Contractor's Name - - ----- --------------------------------------------------------------License # ------- --------------- Phone -----------------------.------ Installation will serve: Residence (o Apartment House-❑ Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------------------------- Number of living units.,_!------- Number of bedrooms ___------Garbage Grinder ------ Lot Size _.-.'S ` ---------------------------- Water Supply: Public System and name -------------------------------------------------------------------------;------------------------------------Private 19 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK;] Size-_ /D-'r - --------- ------------ Liquid Depth -'/---------.-.------- Capacity M.0_0 Type__ --_ Material.__&:r ---- No. Compartments .............. Distance to nearest: Well ___4 ------------_------------Foundation I-vl-------------- Prop. Line -__ _7'._ '� LEACHING LINE 41 No. of Lines ---�----------------- Length of each line._."7D- ._---- Total Length lad------ ----------- r�7 DD �� 111 'D' Box __ Type Filter Material Depth Filter Material ----/T__________________________...___._ _ i Distance to nearest: Well X_�_-_______________ Foundation IP '0 Property Line -------------_____ SEEPAGE PIT Depth ._-� _________ Diameter Number ---------__________.__ ,dock Filled Yeses No i❑ i Water Table Depth ---/-al -----------------------------------Rock Sized ��s�-------------- Distance to nearest: Well _I `- ________________________Foundation _Io_'.......... Prop. Line ------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------•------------I Septic Tank (Specify Requirements) -----------------------------------------------------------------------------------------------------•----- ----- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- O --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------ 3 ok (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 perform yrre of the work for which this permit is issued, I shall not employ any person in such manner as to becoysuct to W a mpensation laws of California." Signed - -- ------------------------------------- Owner By ---------- ----------------- ------------------------------------------- -Title (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------•---------------------------------------- DATE _-T-.s -,7*�---------------- BUILDING PERMIT ISSUED --- --- ----DATE -�-�-----'------------------------------------ ADDITIONAL COMMENTS ----- /Z _fYY - ---- ----.- .ecrrrs '-- -------------------- ------- --------------------------------------- - :_ � -- ------------- --------------------------------- _ ------ ----------------------- --------------------- - ----=------ --------------------------- Date ---- ------------ - incl Inspection by: -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M--