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FOR OFFICE USE: APPLICATION„FOR;,,5ANIYATION PERMIT IPermit No. -�--y--�� ----------------------- ------------ -------------------- (Complete in Triplicate) ------------------------------------ ----------------- --�- Date Issued _14-4___Q--- This Permit Expires >I Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- 00K egulations: JOB ADDRESS/LOCATION ENSUS TRACT _________________________ /6D---- r., � ' ZgS--- - --------Phone. J Owner's Name � 'd�1l�c.---- ---- - - -- ------------- ------=-•--- - - -------------------- ------- Address ---------------------- - _ fir �_ /� city ------- -a-------------------- Contractor's Name License # ------------------------ Phone ------------------------------ C!J/, 1 Installation will serve: Residenc partment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other ------------------------------------------ Number of living units:_-___/---- Number of bedrooms ____Garbage Grinder ------------ Lot Size __*ftg��--�� ----- Water Supply: Public System and name ---------------- - ----------------------------------------------•Private Character of soil to a depth of 3 feet: 5and'❑ Silt 0Clay ❑ Peat ❑ Sand Y Loar�Clay Loam F1 T - "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,) ( Size --------------- Liquid Depth . PACKAGE TREATMENT SEPTICeTNK:Capacity— _ Type/fle—"t- Material __ No. ompartments _ Distance to nearest- Well Zrofea ___________Foundation -----f---- ________ Prop. Line ____ ------ --------- - / LEACHING LINE No. of Lines -----_-/-- ---------- Length h ine______1 -------- Total Length ----- LEACHING _ l- • - •I----- 'D' Boxy_ Type Filter Materi f - pth F �terMaterial --------411----------------- Distance to neares Well ___ --r----- Foundation __ ---- Property Line _________ _ __________ SEEPAGE I { Depth D' ___Z__.__ Number __.-____J_________._______ Rock filled Yes No FV Water Table Depth --------- a _ _ -------.---Rock Size -------- o Foundation / Pro Line _... -•- 41 Distance to nearest: Well ____-._-�----- ------------------ - ---- -- -- p' � REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ------------------.---------------} Septic Tank (Specify Requirements) ------ ----------------------------------------- --------------------------------- ------------ ----------- --------- Field (Specify Requirements) ----------------- ---J--------------------------------------------------------- ----------------- •--------- --------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subidNA Workman' _Compensation laws of California." Signed - ------------------------ Owner BY ------------ --------------------- ---------------- . ----• Title ------------------- -- ---------------- ------- ------------------------ - - ---------------- - - - (If other than owner) FOR DEPARTMENT USE ONLY IF DATE APPLICATION ACCEPTED BY ---------- --- ----------------------------------------- BUILDING PERMIT ISSUED ------------------------- ----------DATE ------------------------------------- ----- ----------- ADDITIONALCOMMENTS ----------------------------------------------------------- - -----=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- --------- --------------------------------------------- ------------------------- ---t ----------------------------------------------------------------- --------------------- --� -- ---------- -------------------------------------------------------------- -- Final Inspection by: ------------------ G_"� Date 1 f SAN JOAQUIN LOCA" HEALTH DISTRICT t ,, E. H. 9 1268 Rev. 5M