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FOR OFFICE USE: APPLICATION FOR SANITATION PERiihi� .�� . ` --------- -------•----------- ---- 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 permitito 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 1 `"" - j ' - -----CENSUS TRACT --------=----__------- Owner's Name ---- Phone - ------------------- -- ------- --------- Address ---- -------1__2q_< -d ..... . ------------------------------ City �1 7 ---� vt --`.*' ,.' Contractor's Name __. -- —, ----_.License #o? ---- Phone _ _ --1��` ��'0-��-�---- �---�-- ��'- �'�--------------- ------.. Installation will serve: Residence ®.Apartment House,❑ Commercial❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number --------------------------------------- --Number of living units:_.____-_ Number of bedrooms ___l -__Garbage Grinder -- --------- Lot Size _I_2-------t/-----_______________ Water Supply: Public System and name ----------------------------------------t-------------------------------------------- ---------------Private Character of soil to a depth of 3 feet: Sand silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ..TD Hardpan ❑ Adobe f7 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,) L PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------- 'V-------------- - -- Liquid}Depth ____�_____.--------..-_-- Q Capacity _'!-z�_ --- Type 0 ' Material_�Q'!W No. Compartments ___�� .......... Distance to nearest: Well ---------_-4�-----------------Foundation; _/_6_/------- Prop. Line .... - ............. Distance f---------�----------- LEACHING LINE [ ] No. of Lines ________�_________ Length of each line-----_�-._-------------- Total Length -- 'D' Box ___! ____ Type Filter Materia_!��/AsrX__-Depth Filter Material _-_ l_0a/ -----__`_------------- �) Distanceyto nearest: Well ----�� ______-__ Foundation - :________________ Property Line ___ _._______.__--.----- 4 SEEPAGE PIT [ ] Depth _-=�-------- ----- Diameter ---------------- Number ---------------------------- Rock Filled Yes CI No C] Water Table Depth ------------------------------------------------Rock Size Distance to nearest^'�We�ll ----------------------------------------Foundation -------------- ---- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ________ ' -- - ------------ Dare -------------------•-------------- Septic Tank (Specify Requirements) ----------------= ti 's---------------•------------------------- = - , Disposal Field (Specify Requirements) --=------------ .--------------------------------------------------- ------------------------------------------------- --------------------------------------------------------------------------------------------------------- --- ---------------------------------------------------------------- `----------`------------------------ ------------------_--------------------- ------------------------------------- (Draw existing and required addition on reverse side) i 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 agents signature certifies the following: "I certify that in the performance of f the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Work mpensation laws of California." Signed __-_ �______-_O-------- -------- -- __o_ ------------- --- --- ------- _ Owner BY ------ ------------------------------------------------------------ Title -- ----------- ------------------- - ---------------------------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------:---------------- - ------------------ ------------------------------------------------------- DATE ------- ---------------•------------------- BUILDINGPERMIT ISSUED ----------' --------------------------------- -------------DATE --------------------------------------------- 0 --------------------------------------- ,` ADDITIONAL COMMENTS C" � T� `� �9 -----1 . t ------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ---_- ---- FinalInspection by: - ----------------------=----------------•----- ----------- --------------------.Date `�- 2 2 -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M