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FOR OFFICE USE: -?:'----APPLICATION FOR SANITATION PERMIT �J� _ �7 1 Permit No. _-/------ ----------- I ---------------------------------------------- (Complete in Triplicate) ------------------------------------- ; Date Issued __..�-�__.- �0 This Permit Expires 1 Year From Date Issued ------------------------------------------- Application is hereby made to the San Joaq�iin 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: JOB ADDRESS/LOCATION ---------- --- ---- - ------CENSUS TRACT YT------------------ Owner's Name -- G - /4 -------------------- ------------= ---------- -------Phone------------------------.._..------ ------------------ - Cit --------------------•-------------------------•-•---- Address - �' -----?TL Y Contractor's Name . ------------License # ---------. Phone Installation will serve. Residence ❑Apartment House-M Commercial ;❑Trailer Court ;❑ Motel ❑ Other ------------------------------------------- Number of living units:-_--6----- Number of bedrooms 7T1-.,j_Garbage Grinder ------------ Lot Size Water Supply: Public System and name --------------------- ----------- ------------- ---------------------------- -----------Private] Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay LoamA Hardpan.N 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.) t1� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1 PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size---------------------------------------------.-- Li -------------------------- Liquid Depth P o, Capacity ------- Type -------------------- Material---------------------- No. Compartments ---- ------------ pY -------- - Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------7------ �. 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 C3 No 0 [ 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) "' r"-- ,t°",r9�'` - -�,-7r�� ----- ---------- (/ -------- i -------------------------------------- / (Draw exii - ------- ------------ ---- -------- ------------------------------------------------------------------------------------------------------------ .,� �s-ting and required addition on,reverse side)_ - •. I hereby certify that Ifhave 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,performance of the work for which this permit is issue d, I shall not employ any person in suchmanner as to becom blect to W an's Co p s ion laws of California." Signed ---�� --- -- --- - --- ---- - ---------------------------- Owner BY ------------- ------------------------------------------ Title _._ ---- ------------------------ --- - -- -- (If other than owner) •w• FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY DATE --- �---- ----- ---------•-- BUILDINGPERMIT ISSUED -------------------------------------------------------- ---------------------------- ------------- DATE ADDITIONALCOMMENTS --------------------------------- -------------------------------------------------- -----------------------------------------------•----------- - --------------------------------------------------------- ----------------------------------------------------- -------------- - ` l� Final Inspection by: ----- ------.Date --- ' --- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M