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t FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i .....�............................................... Permit No. (Complete in Triplicatel ........................ ........ .. ...................................................... t This Permit Expires I Year From Date Issued Date Issued ...47`........... � Application is hereby made to the Sa� 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...d. o _ -- - - .... ......:.................. .... .........CENSUS TRACT ........:........... v.... Owner's Name ........................................:............. ..Phone 3!�/0 _:.�Z.P9-..e..... Address .. ._ _ __.._ _... . . . .......A e--------- .......—. City ..........................._....... �. Contractor's Name ..- - -- • -- -- -- --------------------------------------------------------------License # .........,--•--------.._: Phone .............................. Installation will serve: Residence q Apartment House❑ Commercial ❑Trailer Court 0 - - , : I Motel ❑ Other ----------------------=-------------------- y Number of livingunits ..... __._ Number of bedrooms .... _ -5 , _---Garbage Grinder ------_-__-- Lot Size --d�'--_--�............................ Water Supply: Public System and name -----------------------••-----.._.......--- -•---••--•-•:.....•---•-•-•••-•-••••......--••--......••----•--•..Private' c , ' Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam,M "V f Hardpon,k] 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 sewer is available within 200 feet,) V PACKAGE TREATMENT [ ] SEPTICTANK-f ] Size................................................ Liquid Depth Capacity •------------- Type .................... Material.--------------- No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop:Line ....:................ LEACHING LINE [ ] No. of Lines 1- ............... Length of each line—:................... Total Length ......................... 'D' Box ' Type Filter Material ......Depth Filter Material ,.... °'° Distance to nearest: Well Foundation ..:-------------------.- Property Line............... b..... SEEPAGE PIT Depth __.rf-s _.._+ Diameter ;��: Number .........f................ Rock Filled ...Yes, No.(3 -� Ar • Water Table Depth .._C Q.. ........Rock Size ... l ............ . Distance to nearest: Well ....l.t .........................Foundation ... Prop. Line ...s .....:......... REPAIR/ADDITION IPrev. Sanitation Permit# ............................................ Date .................................. , 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 District: Home owner or licen. sed agentsaignature certifies the following: "I certify thA in the performance of the work for which this permit is issued, I shall not employ any person In such manner as to bec a sub j ct to Word n�opensatlon laws of California."Signed ----... ............................ Owner By -•..........................................._.. .. ........_..---•---•-•--•-----•-••----•---... Title -------- (If other than owner) FOR DEPARTMENT USE ONLY ...... - - APPLICATION ACCEPTED 13Y -- - ---- ---- - -_- - - ---------•----.....--------------------------- .......... DATE --- --...----- BUILDING PERMIT ISSUED -------•------------------------------- -------------=---------:....------------...----- •-- .......DATE _........:. ..............---..._...... ADDITIONAL COMMENTS .......................: . _....... . .......---•--. A - ------•----------------- ------------------------.... •-••------- ------------------------------------------ ....�.. ............ . FinalInspection by. .......................... ...� •----•-•-------------------------------------..................__.......... .I..•.....Date ..... ......._. ... .... SAN JOAQUIN -LOCAL` HEALTH DISTRICT E. H. 13 241-'be Rev. 5M 7/72 3 M