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FOR OFFICE USE: 1 ��_/U APPLICATION FOR SANITATION PERMIT y� -. --� Permit No_ _______________ {Complete in Triplicate} __ I6:- S/ .-� _'_a. "p ",cy �- Date Issued _l U This Permit EzOires 1 Year From Date Issued --------------------------- ------- ---- ---- ------ _ _ _ - -.-- a 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 land eistng Rules and Regu ations: TION CENSUS TRACT , JOB ADDRESS/LOCA f Ph �/ Owner's Name Phone._l a57 )Q, # I Ci# t Address ----- --- ---� ---- --_ Y ------- ----------- --------- ------------ -- r u-� --- ---------License # _- CJS _ Phone _ "g a Contractor's Name ----- ------- --•-- I J. hs Installation will serve: Residence XAparfh t House❑ Commercia.I.❑Trailer Court ',0� Mote! ❑other,----� `'{t�--�.=--------------------------- ,Yr .. ,`D x x-70---- Number of living units:". -. Number of`,bedro66i ___ l 'Garba a Gri der Lot Size l -1< Private ❑ Water Supply-. Public System and name --- '`----=--------------- ------- Character of soil to a]depth9of 3 feet: Sand'El- Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam Hardpan 1] Adobe" Y Fill Material ------------ If yes, type ------------- ------------- i (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'.._ SEPT-IC TANKS_ Size------- ------ ---------- ------ ------------ Liquid Depth PACKAGE TREATMENT [ ] . _ [ ] - i 1 .1I --- Material--------- ---- No. Compartments -------------------- � Capacity ---- -------- Type ---------- ----- Distance to nearest: Well --------------------------------- " Found tion _..------------------- Prop. Line ---•------------------ ' _ g •-___---- Total Length LEACHING LINE [ ] No. of Lines -----------------------I Length of each line---- "-- -- g "`F" " # --------------Depth Filter Material --""_--- - i D' Bow "____.__._-- Type Fi ter�Maferial __ -- Pro er Line. -------------------=---- Distan� to nearest: Well -----------V�`�------- Foundation -.-�---------------- p tY Number Rock Filld Yes ❑ No .0 SEEPAGE PIT [ ] Depth '---------------- -- Diameter --------------- r h Water Table Depth Rock Size ------------------------• 11 --------- -------- ----------------------•--- � 1. foundation -------------------- Prop. Line --------------•--•---- ' ---1 REPAIRfADDITION(Prev. Sanitation Permit# ----------------- - ------- - Date ---�-------------------------- Septic Tank (Specify Requirements) --------- - ----------------- -------------- --- ----- --------------------------------------- ------------------------ Septic Field (SpLcify Requirements) __-_____---" -----"`"----- --r4V�� 622 - --- -- -- T_ --- --------------- + ;Draw existing and required addition on reverse side) I hereby certify that have prepared this applicafiion andi that the work w'slf'be done in accordance with San Joaquin County Ordinances, State Laws; and Rules and Regulations of the Sari.Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: . "I certifythat in the performance of the work for which this permit is iisu4d, I hall not employ any person in such manner as to become subject!#o Workman's Compensation laws oF�California." I r Owner Signed --- - . ----- ------------------------`- ------ ' ------ Title _--------- --- --- ------------------ - ----------------------- BY --- f - - --------------------- (If o than owner) j Q>r EPARTMENT USE ONLY APPLICATION ACCEPTED BY _.__-- A-- i -----. DATE ---1 '` � �r -------------- -- BUILDING PERMIT ISSUED -------.- --- - ---------------•---- -- - DATE ADDITIONAL COMMENTS -__.-._ --------------------------------------- ------------ ------------- ---------------------------------------------- ---------------------------- ------------------ ---------------------------------------- ---- --- -- --- Date - -- - ------- ------------- Final=Ins ection b -- -----. ---- -- -------- ------------- . SAN JOAQUIN LOCAL HEALTH DISTRICT . H. 9 1-'68 Rev. 5M.