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FOR OFFICE USE: �- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -- ------------------------------------------------------ This Permit Expires i 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 -------- ` ------- z ----- ---------- CENSUS TRACT Owner's Name ------ - - - - - - -----Phone-G'@ -.�-"�..�..'.��_ : Address -------------------- '' - 1- _mitY --- ---------------------- Contractor's Name ---t _4Z - -- - ---------- ----�' ----- -- ---•- -- -.License # Z-0_�/_/------- Phone --- Installation will serve: Residence VApartment House-E] Commercial ❑Trailer Court i[] ] Motel ❑Other ----- --- Number of living units:-----.- Number of bedrooms --___�___Garba_ge Grind e Lot Size ------ Water Water Supply: Public System and name _________________ _ ---•-------------------------------------- __..Private ❑ ---- - --------- ------------------------- 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 -__-____-__--------------(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 [ ] J SEPTIC TAN kJ ] Size____________________________ :-- Liquid Depth ------------------""-- •-� r Capacity ------ ---------- -- Type`----- -=`----------:Material---------------------- -No. Compartments ---- Distance to nearest: Well - � ----------- "-----==--•----Foundation -------------•-------- ,Prop. Line ----------------•----- LEACHING LINE [ } No, of Lines __.-________----------- Length,of each lineA_'._"-----_-_-____------ Total Length 9 'D' Box ------------ Type Filfer,.Material Yp Depth Filter Material ----------------- -------------------- Distance -_--__"--__-"_"-_- _____________Distance to nearest. Well __' Foundation ----------------------- Property Line. -- - - -- SEEPAGE PITDiameter----! SE _ [ ] Depth -------------------- ------------ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth -------------------- ------------ ---------- Rock Size 9 Distance to nearest: Well -----------t _ _ ----"--------------------Foundation --"__.-_- __------- Prop. Line -_-_ ___._-..._� REPAIR/ADDITION(Prev. Sanitation-Permit#-= ---------------------------------- Date ............. Septic Tank (Specify Requirements) ------------------------------ !: I Disposal Field (Specify Requirements) __-----___-_ t Q_� fr r i --- t i - - ---------------------------------------------------------- f 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'Joaquirt'L6ecil 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 issued, i shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." _ Signed ---------------------- ___"_______ ___."_-____ !Owner t ti BY ------------------ -------- Title - - ----------------- --- ------------------------------ f other th owner) _------------ EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- - f DATE - / --------- --------- BUILDING PERMIT ISSUED -- --- - - --=' �-�- _. ._ - .._ "... _-�:,: ._ -DATE --------------------------------- DITIONAL COMMENTS -___"-- _ -- � ---------- ---- . .p . �; � ;_,- i ==-- ------ --------------------------------- -------------- - -- ------------------------------------------------------------- ---- ----------'----------- ---------------------------------- ------------------------ Final Inspection b i 7/" - p Y° -------- -- ----- ----- - - -- - ----- - ----- - -----------------------------------------------------------Date ----' --=- SA JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'68 Rev. 5M C