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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � 4 --V cam, Permit No. " :77: -- ------------ ----- ---- ----- - (Complete in Triplicate) ----------------------------- Date Issued This Permit Expires 1 Year From 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. 49 and existing Rules and Regulations: . ------�- t5 CENSUS TRACT --------------------- JOB ADDRESSjLO A ION .- � ---- --- " --- �/ � ..Phone 2Z 75-_� -j-�- (O------ Owner's Name _-J-V ----- �r ` I ----- CitylCD ` ' Address Contractor's Name ----------------------- --------------------------------------------------------------License # --- ------------- ------- Phone ------- ---------------------- + Installation will serve: Residence P"A"partment House❑ Commercial;❑Trailer Court ❑ IMotel ❑Other --------- --------------------------------- Number of living units:___ Number of bedrooms _73------ Grinder ----.___.__ Lot Size i Private ❑ I Water Supply: Public System and name --------------------------------- -------------------- Character of soil to a depth of 3 feet- Sand'er"I"Silt{] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe'❑ Fill Material ------------ if yes,type ---------------------------- j (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No ptic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK f I Size ------- Liquid Depth -------------------------- V i y ZI T e Material- e-------- No. Compartments -. ------- Capaat '_ . -- _ -- Yp I Foundation _-- Pro Line ----------•----,•----- x Distanceito nearest: Well ------ ---------- p' �' ` I` t 9 Total Length _ _-- - LEACHING LINE [�No. of Lines --- ------- Length of each line.------ -- y t 'D' Box ------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to 'nearest: Well ------------------------ Foundation ------------------------ Property Line _________-----------..- 4A. —-----------------"" Number --------------------- - Rock Filled Yes 0 No ' SEEPAGE PIT [ ] Depth j- Diameter --------- I Water Table -Depth ------------ Rock Size ------------ -------- --- Distance to nearest: Well ------------------------------------ •--Foundation--------------------- Prop. Line -------- ------------- REPAIR/At3DITlON(Prev. Sanitation Permit# ----`=-- -------------------------------- Date ----------------------------------1 d I. 1 Septic Tank (Specify Requirements) _---sem ��- �=- `� Disposal Field (Specify Requirements) -------------------------------------------------------------------- ----------- --------------------------------------------------- ---------------------------- ----------- -- _ _ -__ , ----------�---------------`---------- -------------------- ---- -------------- ------- I (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 i 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: $,"I certify that in the performance of the work for which♦his permit is issued,J shall not ewtploy any person In such manner as to become subject to Workmdn's,6rmpeniati.on laws of California. Signed ---------------i-------------- Owner { B -- - - - ---- ---------�--- -�------------- Title -------------------------- (If other---------- than owner) , IF.OR DIEPMtTJAENT USE ONLY � APPLICATION ACCEPTED BY = DATE t rf --------------- BUILDING PERMIT ISSUED ------ ------------------------------------------ -- ---------------------------DATE ADDITIONAL COMMENTS ----------- ---- --- ------------------------------=----------- ------------------------ �f� 7f�-.,fie Gtr �//�.�-/ -------------------------------- ----------------- --------- ------ - ----- ------ --- - Dat - Final Inspection bY- --------- --- ------------ - I SAN JOAQUIN LOCAL HEALTH DISTRICT f . 4 E. H. 9 1-'h$ Rev. 5M