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FOR OFFICE USE: - APPLICATION FOIr-SANiTATiON PERMIT ----- - --------------------------------------- (Complete in Triplicate) Permit No. ----------" ----- This Permit Expires 1 Year From Date Issued--- sueDate 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .. Owner's Name ., _ _-..----------CENSUS TRACT -3 Address ---- ----------------- ---------------- ----P one -----------I ------------- --- -� �13� < 7.1- Cit Contractor's Name -- ►----------------------------------------------- ... - ------------ - -------------------------------------License # ---------:-------------- Phone Installation will serve: Residence a tment House,C] Commercial ❑Trailer Court ❑ Motel ❑Other Number of living units:-----/-__-_ Number of bedrooms __ -----Garbage Grinder ------------ Lot Size ---------------------- Water Supply: Public System and name --------- ------------------------- Character of sol! to a depth of 3 feet: Sand'� Clay --------------------------------- _Private Silt ❑ y ❑ Peat❑ Sandy Loam [] Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Materia ----- ------ 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,) � PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------•----------- ------ Liquid Depth ------------ Ca acit -------��.--••- P Y -------------------- Type ---------- -------- Material------------------ --:� No. Compartments ______ _ W Distance to nearest: Well ------------- -------------- ----Foundation ---------------------- Prop. Line ----------------•----- Gj LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------------------------------ Total Length -------------- ' Box ------------ Type Filter Material __________________-Depth Filter Material Distance to nearest: Wel! ------------------------ Foundation _-,___-___-- SEEPAGE PIT [ ] Depth ------------ Property Line -- —� ------- ------'Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No �❑ Water Table Depth --------------------- ---------------- Rock Size . Distance to nearest: Well --.___---------------------- -- -----Foundation - -------------------- Prop. Line ----------•-----•----- -� REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------------- Date ----------------------------------1 � Septic Tank (Specify Requitements) ____________________ Dis osal Field Specify Requirements) -------- ----------------_ 7 _"e.''rt ----------- /✓ f (Draw e4isting 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 fallowing: "I certify that in the performance of the work for which this permit is issued, i shall not employ any persoin such as to become su Iect to Wor an's Compensation laws of California." n manner Signed _.� �--�. - ----fl- - --------------------------- -_ Owner BY - --- -- -er-- -- - - -----------than owner) (If oth ----------------------------------------------------- Title .--------------- - FOR D ARTMENT USE ONLY APPl�fCATlON ACCEPTED BY _- _ - _�_-_ ��...._.— BUILDING PERMIT ISSUED ----------------- -------- ------------ -----=---------------------------I DATE --- ---- .� ADDITIONAL COMMENTS -- ------------------------------------------ --------------DATE ------------ - ------- ----------------------------------------------------------------------------------------- ------ ------ ------- -•----- ------- ---------- Final Inspection b -- ------- ------- ------ ------------------------------------ --- - -- ------- -------Date -_�:'>:�*3__�_�T---------- "- SAN JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'68 Rev. 5M