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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ---------=----------------------- This Permit Expires 1 Year From Date Issued----------------------- Date Issued __ _._A: __-_d --------------------------------------------------------- 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 an existin es and Regula ions: �C 1 lFl� tiweP_ JOB ADDRESS/LO TION ,c __Y ZZ_e - ---------------------CENSUS TRACT -------------- ............ Owner's Name ) �`-`-�-----ate- '�2.., s -------- Phone _ ��i'.S $1 Address ------- - d 4 < ---� tLyv Ci �`7__ -- Contractor's Name ----- ------ --=-- - -- -- --- -------------- L� �-�'' >1 .License # p_,q�[ Phone Installation will serve: esidence bKeApartment House Commercial ❑Trailer Court i❑ Motel ❑Other-------------------------------------------- Number of living units:------_----- Number of bedrooms�---I-------Garbage Grinder ------------ Lot Size _%5�Q--------------------------------- 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.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) D et � PACKAGE TREATMENT { ] SEPTIC TANK n Size _7/-_SV`;_4_/�'``._______ _ Liquid Depth -- .____-_/a�._.-__---------- Capacity M_00___,__ Type alt - Material &nCU -._ No.� Compartments _____ t....�..... f Distance to nearest: WL-11 - 11 J!5-w------------------ _ -----Foundation ---1-0-1 Prop. Line .__.__._.. .._..__.___ LEACHING LINE No. of Lines Length �oteachli e _�1V Total Length _ _- ----------- --------------- 'D' Box _.___-_____ Type Filter Material _- _- Depth Filter Material ___-_1-- _ .................. Distance to nearest: Well .�Q ..._.____ Foun at __ -------------- Property Line _-______-. _� SEEPAGE PIT [ ] Depth __-_ --------------- Diameter ________________ Number ----------------------- Rock Filled Yes ❑ No i❑ �Q Water Table Depth ------------------ ---------------------Rock,Size -------------------• ----------- Distance to nearest: Well ----------------------------------_.....Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------------ ---) . SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ----------------------------,..---------------•------_-- Disposal Field (Specify Requirements) -_._______._ ---------------------------------------------•----------- -------- --- - - - -- ------ - ---= (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: "1 certify tin the perform n of the work f r which this permit is issued, I shall not employ any person in such manner as to b om subject to Wo n's `npe sa on laws of)California." f Signed ------ ------- � -M Title ------------------------------BY - - ---- ----- - (if other than owner) FOR DEPARTMENT US OA4L(, APPLICATION ACCEPTED BY ----------------------------------------------------- dxs DATE 4'3ta BUILDING PERMIT ISSUED ------------------------------------------------------- ----f- -----------------DATE ------------------------------------------ ADDITIONAL COMMENTS --------- ----------------------------- ---------- ------- --------------------------------------------------------------------...... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=---- -------- ________________________________________________________________________________________________________________________________ _ _____________________________________________________ Pf(_ ------- _________________________________________________________________________________________________________________________________ _ 1_ _ _ _ _ _ - ./_ ____-_-_ Final Inspection b _-_-_---__ ...........Date -- �..6_ _._ __ - RICT SAN JOAQUIN LOCAL HEALTH DI T E. H. 9 1-'68 Rev. 5M