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FOR OFFICE USE: f APPLICATION FOR SANITATION PERMIT ---------------------------- --- Perm it.No.Eo_f__6 7 3 (Complete in Triplicate) This Permit Expires 1 Year From Date IssuedDate Issued 10p5(c.ation 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: JOB ADDRESSAOCATION S_1=_._ �� �►- -[�_- r�" - - --'---CENSUS TR» --005--0570-13 Owner's Name ----eollne- ` } -- -------------------- - - -----------Phon - --------------------- Address -------s c0 - 6-e-l' ``�' ------------------- City ----------- :� -------------- 1---•-- f n 1 Contractor's Name : -------------------------------------- License # Phone ------------------------------ Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ;❑ . Motel ❑Other --------------------------------- Number of living units:-------1 ___ Number of bedrooms _____Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name -- ---------------------------------------------------- -------------------------------------------------------Private 1 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 `3 , 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.) N , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] w- . . Size------------------------------------------------ Liquid Depth ------r,-.----.--•----•-•- CapacitY -------------------- Type --------------------- Material-.-------------------- No. Compartments ------------------•--- r Distance to nearest: Well --------- --------------------------Foundation ---------------------- Prop. Line ---------- -----.-•- LEACHING LINE No, of Lines " E --- ------ Total Length [ l ---------------------- '"Length of each line---------- -- - -----------•-------•---•---- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------ ------------------------------------- V' Distance to nearest: Well ________________________ Foundation ------------------------ Property Line y SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No 0 0. Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------___........ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------------------------------------ ---------------- DisposalField (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 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 beco subject to Workman's Compensation laws of California." Signed - ---- --------------------------------------------- Owner BY --- - ---- - - --------------- Title ` (If other than owner ----- --- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ------------------------------------------------------- DATE ' SGP------------------ BUILDINGPERMIT ISSUED ------------------- ------------------------------------------------------------------- -=--------------DATE ------------------------------------------- - - ADDITIONAL COMMENTS ----------------------------------- --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------- ----------------------------•-- n { ------ Final inspection by: -- ------------------- -------------------- --------------------------------------Date -7�+l = - - --- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M t