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FOR OFFICE USE: '" y� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ---- ------- ----------- ----------- ----------- ------- Date Issued _lCl-- 70 _ _ This Permit Exp fires { 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 rdinance No. 549 and ex' ting Rules and Regulations- ENSUS TRACT -------------------------- JOB ADDRESS/LOCATI '� " i_ c ,Phone3 Owner's Name -__._ -- Address ------ -------- -=-- - ------=-------- ---- ---- ------------ - - City -----d---- ---- ----------------------------------------------------- Contractor's Name -- ------.License #Ira-_�1--- Phone Installation will serve: Residence ❑ Apartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other -------- Number of living units-------------- Number of b Brooms ----__-____.Garb a ioder ------•------- :_ - Lot Size __ c°1 Water Supply: Public System and name ------- ---- -- --'Peat ----- ------- - -- ---------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ fill❑ lay ❑ Peat❑ Sandy Loam Clay Loam ❑ t Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ___--"__--___---___--__--_ (Plot plan, showing size of lot, 1 ication of system"in`Telatiori to wells; }wildings;`etc. must be placed on reverse side.] NEW INSTALLATION: (No septic tank or seepage pit permitted-if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------- `-------`------------------------ - Liquid Depth .---------- 0 Capacity E Type -: Material-------------.- ----'- No. Compartments ---------------------- PY =.-------------- € -- 1 4# `-Foundation -------------------- Prop. Line ---------- ------ Distance to nearest: Well ."_:--_ I * i. 4 ---- Total Length ---------------•------------ LEACHING LINE [ ] No. of Lines:_.____________- ---_ Length .of each.line'-.--_---_.___._---._. 'D' Box J--.-_•-.- Type Filter Material --------------------Depth FilterjMaterial _---_. _ ------------ # t 'r -} -------- Distance to nearest: Well --------------------- -- Foundation ------------------------ Property Line ________..--.--_--_-.-- .. s No i❑. Depth Number ------------------- Rock Filled Yes ❑ SEEPAGIr�PIT [ � � _ Diameter -____ _-__ 4 Rock Size __ Water Table Depth -_ ----------=------------------ ,. nearest-. Well ----- ----�----- •-- ------------------Foundation -------------------- Prop. Line ---------------------- D9te -------(Prev. Sanitation Permit# ____-.-_ D e ______________•--------- ---------------- Distance a Weare -- --------- t 'Septic Tank (Specify Requirements) __-- ___---- --- - r , r ------ f r Disposal Field (Specif rtRequiremnts) o - --• "�� """ ' - -- ------------- -- ".� s (Draw existing and required addition on-rev�rse side): - - �} �s I hereby certify that 1 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: 11 certify thaf iW he work for which this permit is issued, I shall not employ any person in such manner as to beco ohipensati laws of California." Signed _ Owner tTitle -----61A-- - ----------------- --------- ---------- - ---- - - ----------- t ( OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE --- --70 --------------------------------------------- BUILDING PERMIT ISSUED ------- ------------------------------------------------- � DATE -------------------------- ------- �--- ------- ---------- ------- ---- --------- ADDITIONAL COMMENTS -------------- --- r------- _------- - ----�`----------- - -------------- --- -- -- ------- ----------------------- -------- ---- ---- ------ ----- -- -- -- -------------------------- - ---- ------- ----------- --- - ----- __Date - ---� �-- - . -------- Final Inspection by: -- ------ ------------ --Com''-- "--- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M