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FOR OFFICE USE: �. 9-_gV� 1 !b p M APPLICATION FOR SANITATION PERMIT - ---.-- :11 ` ----•------------ ` (Complete in Triplicate) Permit No: ------ ------------ --------------- -- --------------------11--------------------------- --------------________________________________-_____________ This Permit Expires 1 Year From Date Issued Date Issued Application i 11 s 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 ADDRE 11S/LOCAN)TON __7 -----A'Y-0--------------------CENSUS TRACT -------------- ------------------- r : � .2Ownes Name B D 7 Addresskl Q a[ �11t. --------• City Q _ Contractor's Name .- _ 1�1- -- (} ,-__.a.License # - U3�rPhone - _t�77-! Installation will serve: Residence partment House[] Commercial :❑Trailer Court ;❑ # Motel ❑ Other ----------------------•-------------------- r l 6 OrX Number of living units:--- Number of bedrooms _ Garbage Grind41y ______._.. Lot Size, ............ Water Supply: Public System and name -- Crte- ____________Private ❑ } Character of (soil to a depth of 3 feet: Sand' ilfi [] Clay ❑ Peat❑ fLoam -❑ Clay Loam.E] �I Hardpan ❑ Adobe'DF�jill Material --------E- 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 [ I SEPTIC TANK f ] Size------------------------------------------ - -- Liquid Depth ------ ------------------- Capacity --------------- Type -------------------- Material---------------------- No. Compartments ---------------------• Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------------_.-.. LEACHING LINE [ ] No. of Lines _________ Length of each line---------------------.------ Total Length ----------------------------- 1 D' Box --- ........ Type Filter Material --------------------Depth Fitter Material --------------------.----------------------- . 3 Distance to nearest: Well ------------------------ Foundation ------------------_------ Property Line .-_---_-.----•-._..-..... SEEPAGE P1T; [ ] Depth -------------------- Diameter ---------------- Number ------------------------_--- Rock Filled Yes ❑ No 0 F 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 ----�--- ----- ---- ------- -------- ------------ ---------------. --------------------- ------------- ------- ------ ---- ---------------------------_---- --------------- _______________________ _ -------_._-------------- .__-------------------------------------._____________._-_-___-__._______._.________-___._______ Il (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 thai in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to bu efiz W-7-7.7- � f California." Mu Signe ec s � Work an s Com a sat* laws o By ............__1--------1--------- --------- ------------ Title ------------------ - - ----------------------------------------------------- :f(If other than owner} ' II FOR DEPARTMENT USE ONLY hr APPLICATION ACCEPTED BY --------- ---0j —=----------- ------------------------------------- DATE ----�Z �'------ ------------- - -------- -- BUILDING PERMIT ISSUED -------------------- --DATE -------------•------------------------- --------------------------------------- ADDITIONALI1COMMENTS ------------------- - ------- -- ` ------------------------- ----------------------------------- - --------�-------- --------------------------------------- ----------------- ------------- --- -------------------------------------------------------------------------- ------ --------------- i1----- --•--•- --------------- -----0------------------ ----------------------------------------------------------------------------------- � � --=------- -------- - ---- FinalInspection by: -----------------------� '--- - - - -t�.P--------------------------• - ------- ----------------Date _.f -- - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1'='68 Rev. 5M