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FOR OFFICE USE: APPLI�TION 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 construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 7V y JOB ADDRESS/LOCATION . _ 7f,__!!_�r�--- -------------- CENSUS TRACT Owner's Name _ - ,PC-- c -- r Phone . Address ----------- ---------a-49--t----- �-�r�--------------- ---------- ----------•--- City ------o'�- -'�`'---------------------------- � e _ ------ License # ._f ' -3 Phone ------------------------------ Contractor's Name __. -- ------ ---94- Installation will serve: Residence partment House❑ Commercial :❑Trailer Court 0 Motel ❑ Other -------------------------------------------- Number of living units------f.----- Number of bedrooms __a-----Garbage Grinder ------------ Lot Size ---------------------------.--------------__ Water Supply: Public System and name - -------------------------------•---------------- Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E] Peat F1 Sandy Loam Olay 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 seepfin a pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ SEPTIC TANK:[+ _`____.__. ------ Liquid Depth _ __�_________________ ,�2 Capacity _� .Q.a_ Type -_ Material --- No. Compartments _-____.._._.•._-....-- Distance to near t: Well ___ __________________Foundation _____f0_ -_____ Prop. Line --S_--------------- LEACHING LINE [C] No. of Lines _____�_______-____ Length of each line__-_-_-�------------- Total Length ---------------- `D' Box Y-_--.__ Type Filter Material ---SA--------Depth Filter Material -_- ------________________________ � Distance to nearest: Well _-JAP_r_______ Foundation -------- _17-1 Property Line �______ __________ S��T [� Depth -----1?-ft etex �--x_- 0-- Number ---------�-------------- Rock Filled Yes No Water Table Depth ---------------- �-- -----------------------Rock Size -1-1 X ------------ f Distance to nearest: Well --------------UQ_P..................Foundation -------i-0-0 Prop. Line ---- .-------.------ k REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ ------ Date -------------------f------_-------) Septic Tank (Specify Requirements) --------------------------- ---------------------------------- ------------------------------------------------------------------------- --- DisposalField {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 oftheSan 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 to Wor Tan's Compensation laws of California." Signed ---------- Title--------------- ------ ------ Owner _ ----------------------------- ---- --- - - (If other than owner) FOR _DEPARTMENT USE ONLY APPLICATION ACCEPTED Blc>r ----------- ---- --------------------------- --------------------------------------- DATE '=c . `7d---------------- BUILDING PERMIT ISSUED ------------------------ - : - -----DATE ------------------------------------------- ADDITIONAL COMMENTS ----- �`"'- ---- Q/G - ------------------------------------------------------------------ ------------------------------------------------------------ ---------------------------------------- -------------------------------- ---- ------------------------------------------ --- - --- ---------- ------------------------------------------------ -------------- -------------------------- - - Final Inspection by - - ----------------------------------------------------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M