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w FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- - - ----------------- -•------------------- Permit No. __�-S-q�O. (Complete in Triplicate) ---------=----------------------------------------------- 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/1_TI -----`----- ----------- ----------------- _-Zlel--------------------- ---------CENSUS TRACT ---- Owner's Name Name ____ __ ___________Phone Z. _ Address , -- ---- = ---- -- ------------------------ -------- -- _ City Contractor's dame L�--- --- -------------------------- ---------------------------License # � Phone zf� __ Installation will serve: (U/ esidence VX-Partment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:------------ Number of bedrooms __2_-_—__.Garba_ge 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 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 ----------------------------Foundationermitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size-------------------------------------------- --- Liquid Depth -------------------------- Capacity -------------------- Type ---- --------------- Material--------------------- o. Compartments ---------------•------ Distance to nearest: Well ----- -- ------- ------_------- Prop. Line --------.------------- t LEACHING LINE [ j No. of Lines ____�_______________ L ngth of each line___��______-- .___ _ Total Length ----------- ---------------- DSP b' Box --- -- ----- Type Filter M tenial _____Depth Filter M tenial 1 I+0 Distance to nearest: Well ________ _______________ Foundation ----- ------------ _____ Property Line SEEPAGE PIT [ ] Depth ____ --------------- Diameter _______________ Number __.------------------- _____ Rock Filled Yes ❑ No C] Water Table Depth ----------- ----- ------------------------------Rock Size --------- --------------------- Distance to nearest: Well ._ •-------------Foundation -____-- Prop. Line --......-............ - REPAIR/ADDITION(Prev. Sanitation._Permit# _______________ _ _________________________ Date ______________--_ -------------- �LL Septic Tank (Specify Requirements) --------------------------------------------- (I------------- ------- ------'-------------------------------• --------------- ----------• ��1Y Disposal Field (Specify Requirements) ___ fJJ (�______77 fT_ /I��---------- Pe -- 0-F---- EX rl1>m S- ------------ - ------------------ -------------------------------------------------- ,3 --------eF-------- -- --- V19-6. P -----c-A45uWrc) 4Xc5 > `-` t3 -- --------------- (Draw _ existing and required addition on reverse-'side) a } I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Law's, 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 issued, I shall not employ any person in such manner as to become subject Workman's Compensation laws of California." Signed � s f/ -f --------=----------------------- ------------ Owner BY --- ------------ ------------------------------------------------------------ Title --------- ---- (if other than owner) �}— Q FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------1---t8-n - DATE l - 5 ------------------------------------ - BUILDING PERMIT ISSUED --------- -- -------------------------------DATE ------•----------------------------- ADDITIONAL COMMENTS ------ - ------ -------------------------- ------------------------------------- --------•------------------ --------------- ---- --- ----------------------------=----------------------------------------------------------------------- ------- -------------------------- ------ --------------------------- - - ----------- ----------------- Final Inspec . �j p / 'J'�------- ----------- - -- ------------------------ -------------- .Date --- ----- `,----:.�jy�_: � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M