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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- - -- -- Na. (Complete in Triplicate) Permit --------------------------------------------------------- ---------------------------------------------------- This Permit Expires Y Year From Date Issued 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION t0�7,1 � 1 �------ ------ -----------CENSUS TRACT -------------------------- Owner's Name + C --_ 7"Ake J47 -- ✓_•---�--` - '�=- --�- ----� ---- ----- --- -- -------- -----Phone T�---/------- AddressSdo City __ Contractor's Name ,_-- _ -- /------- License #ads%/? -- Phoned'_ � Z Installation will serve: Residence t4Apartment House ❑ Commercial ❑Trailer Court ,❑ Motel ❑ Other -------------------------------------------- r � r Number of living units:_-_�__. Number of be �s ________Garbage Grinder _._________ Lot Size _7S _�*t---------- ----------- Water Supply: Public System and name -- ---. p -------------------_--_--------__--__-_----_-_----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam ❑ 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r M0 PACKAGE TREATMENT [ ] SEPTICTANK� Size-/-/ I ____________ Liquid Depth ______��__---------------- Capacity I_IR_Al�____ TypeP�__ __ Material_-/}?—____ No. Compartments ____ ---. --- r � Distance to nearest: Well --------------Foundation _,d_____-_._____ Prop. Line ____-� �.__.___ LEACHING LINE No. of Lines ---,3-------------- Length of each h a-___-9_�--------______ Total Length _ OP_IQ.......__..3 D' Box ___�___-- Type Filter Material_ ___ Depth Filter Material _____ 0 Distance to nearest: Well _o7 749�_-___ Foundation __ ------------ Property Line ---______--------_...... . SEEPAGE PIT [ ] Depth ---- Diameter ______________ Number ---------------------------- Rock Filled Yes ❑ No C] Water Table Depth ------------------------------------------------Rock Size ------- --------------------- Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date ------------------------------.---) Septic Tank {Specify Requirements) ---------------------------- ------•--------------------- ----------------------------•-----------------------•---- DisposalField (Specify Requirements) -------------------------------•----------------------------------------------------------------- ----------------------- ------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 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. Nome 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 bec sub'ect to workma 's Compensa uo laws of California." Signed --- --------- ---. Owner `Y ♦ ---- Title ---------------- --- (if other than owner g * ]FOR DEPAitTMENT USE ONLY APPLICATION ACCEPTEDBY . ------------------------------------------- - DATE a' 1 � --------------- BUILDING PERMIT ISSUED -_-- __-- ----DATE -------------------- ---------------------- ---------------------- ADDITIONAL COMMENTS - -J-7r = ' - -------------------------------------------------------- ----------- --------------------------------- -- -- --- 4-- _---------- -------- -- --------------------------------------------------------------------- - -- ------ - --- ------- ---- - - ------- ----- - -e-ction- Y�- -------------------------------------------- --------------------------------------- r - - ---- -`- -- ------ ------------------------------------- ----- ---- --------------- -----------Date � - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M