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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) 7_`�- ----- ------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued -- ---- I 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 ._/;O_t:'7 , ....-_,F.- h7/7'r_74�_�1'��$x�__��P1/� CENSUS TRACT �5-�-�----------•----- Owner's Name _ /.� �l�Q/_M-------�/_SQ/ /5------------------ -------------- ------Phone."._11 /.3� Address ---P_D Z-_---.--15 TIN--- f l_V V4_� n oC l _ _ Contractor's Name --- ( V__I_ ?------LU"N_S_FfJaQ-------------------------------License # ------------------------- Phone 7"__-_,W31.. Installation will serve: Residence X Apartment House�❑ Commercial ❑Trailer Court ;❑ Motel ❑Other --------------------- Number of living units:-----/----- Number of bedrooms ___'___Garbage Grinder __yZ_4_ Lot Size ------- Water -----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 permitted if public se er is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK Size_' _ _A; ---------------- Liquid Depth __�1f1____.___._ Capacity/ — Typ _ 4V.,0Mafierial _ '� No. Compartments 4---- _ O -__._ til Distance to nearest: Well _ %A________________________ f _ __ -_______ Prop. Line Gib--`-------- 0 LEACHING LINE [V No. of Lines ------2,____________ Length of each line----JO_Q------ ------ Total Length _-2-0-0------------- Z' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- --------------------- Distance ----_-__-_--- -----Distance to nearest; Well _f 25__ _________ Foundation _�� _________-_-"" Property Line _________________ SEEPAGE PIT �] Depth __..� Diameter __1r2_____ Number ----------�_____________" Rock Filled Yes ❑ No �❑ �o Water Table DepthQ /_ Rock Size -------- -------- X Distance to nearest: Well ----Ca J_Foundation �f� �',�iQ*�rop. Line _.,401PS- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------_--------------_-___------I P Septic Tank (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 Distrltt. 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 becom s bject to ork 's Co�enqaos of California." Signed ------. ----- -- ---------------- Owner BY --- -- ----------- - ---------------------------------------------------------------------• Title ----------- --------------------------------------.--------------------- (If other than owner) FOR DEPAIRTMENT USE ONLY APPLICATION ACCEPTED BY ---- -- --------- --- - --- - -- --- ---------------------------------------------------------- DATE ------------------ BUILDING PERMIT ISSUED --------------------------------------- -- - -------------------------------------------------------------DATE ADDITIONAL COMMENTS COMMENTS -------------- - ------ - ------------------------------------ --------------------------------------------------------------------- ------------------------------------- ----------------------------------------------------------------------------------- --- --------------------- Final Inspection by: ------------ -- ------------------•---------- - ------------------------ Date " _'_ �---- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M