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FOR OFFICE USE: I 0061 W 1 aao APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) __________________________________ __ ____________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to gpostruct and install the work herein described. This application is made in compliance with County Ordinance No. 5449_66.existing Rules and Rg lotions: ` - CENSUS TRACT-- ilG� ,. JOB ADDRESS/LOCATION --------------'�-----,�--�—[�j-1----------------- ----------- Owner's Name _ I ----- ---------- -------- ----- -----------Phone ------------------------------------ Address -------T e----a L'_-0 ------=------ �t J, City 5 B ----------:------------------------------•------ Contractor's Name ---�.- ------_ --.--------- ---------�� rL _license # _d6. Phone __.---------------------__---- Installation will serve: Residence Apar tment House, Commercial ❑Trailer Court i❑ Motel ❑Other ------------------------------------------- Number of living units:_______ Number of bedrooms ---/-----Gar a Grinder J40----- Lot Size A----------- ------------------------- --- Water Supply: Public System and name ------------------------- ---------------- - - Private ❑ Character of soil to a depth of 3 feet: Sand❑ Solt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ _n Hardpan ❑ Adobe;k�r_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 ZE if public sewer is available 200 feet,) � � 7 s � r PACKAGE TREATMENT � SEPTIC TANK[//] _ � _______________ Liquid Depth --- �----------- Capacity -- - -. Capacity ./Z-t _4-TypeMaterial_ ____ No. Compartments ._21............. s or Distance to nearest: Well __ ---- ---------_-----------Foundation ---_�__o-------- Prop. Line .... ------------ LEACHING ____-----_ LEACHING LINE No. of Lines f -_ _ Length o each line_______- i�_�________ Total Length ,_.__-R-P_`_ -- - --------- 'D' Box ------------ Type Filter Materia __ _. _ .__ -----Depth Filter Material ----�.'�__"-I..................:.... (� Distance to nearest: Well -_______._-_._-___.__ 'ou dation ______________________ Property Line -___----_- ............. SEEPAGE PIT [ ] Depth -------------------- Diameter ___________a____ Ntmber Rock Filled Yes ❑ No I❑ Water Table Depth ------------------------------ ----------'-------Rock Size -------------------------------- Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ...._.... .......... REPAIR/ADDITION(Prev. Sanitation Permit# _.__._-.____________________'--_--j�--.--76ate __________..__-____-________--.-•_) Septic Tank (Specify Requirements) ---------------------------------------------------------------------- ---------------------------------------«---------------------------- Disposal Field (Specify Requirements) ------------------------ ________________________________________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_----- (Draw existing and required addition on reverse side) I hereby certify that 1 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 that n he performance of the r for which this rmit is issued, 1 shall not employ any person in such manner as to bec s jgtt to Worldman' Co satio laws of lifornia." Signed --- G ' . -- ----- -'--- -- ------- -- -- ------ By ---------------------------------------------------------- =- -- --------- -------- - Title --------- -- --------------------------------------- (If other than owner) f FOR DEPARTMENT S NLY APPLICATION ACCEPTED BY ------------------------------------------ ------- DATE --- � �� ---------- -------- BUILDING PERMIT ISSUED ------------------------- ------------------- --------- ----------- ------ ---- --- ------------------DATE ------------ ----------------------------- ADDITIONALCOMMENTS _.------------------------------------------ ----- -------------- ----------------------------------------------------- -------------- --- ---------- ------------------------------------------------------------------------------------------------------------J- -"`-------------,--------------------------------------------------------- -- ----------- ------- -- - ----- - ---- -- --- - - -- -------- ----- Final Inspection by: - ------- ---- - --- - g eA-------------- Date �: ��- � -- -- SAN JOAQUI L- LTH DISTRICT E. H. 9 1-'68 Rev. 5M