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4 FOR OFFICE USE: R SANITATION PERMIT 0-1 APPLICATION FOR 13-41-33 Permit No- --------------------- ----- - ------------ ----------------------------------- (Complete in Triplicate) ------- ----- Date issued �`f/7 3_.. This Permit Expires 1 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT N _ -_0 O_ -�, 4 '�,.'4 ------¢ --------------- -CENSUS TRACT ----------- -- ----------- Owner's Name ------ -------Phone ------•----- � _ -city I + � Address ---- - ��-- - -- -------------•---------- Contractor's Name ----c *License # � �� Phon -------------- -------------- Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court l❑ Motel ❑ Other Number of living units:---)----- Number of bedrooms ---Garbage Grinder ------------ Lot Size ____-_ ------- Water Supply: Public System and name ____________________ ---------------------------------------Private Character of soil to a depth of 3 feet: Sand' ilt C] Clay [:1Peat El 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,) Size--- -------------------------------------------- Liquid Depth ---------------•-----.----- PACKAGE TREATMENT [ ] SEPTIC TANK f ] �(} Capacity t Type ----------------------------------Foundation ----------------------Prop. Line -------•------.•----- T e -------------------- Material---------------- _ No. Compartments � Distance to nearest: Well __ vl LEACHING LINE [ ] No. of Lines _.______ -------------- Length of each line__------._____-_.__-_-_.___ Total Length __--______.___...____...___ v D' Box --------- -- Type Filter Material .-'------------------Dept Filfer Materia! -------------------------------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------------------ SEEPAGE PIT [ ] Depth -------------------- Diameter '-------------- Number' --------L------------------. 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) ------------------------------------ -------------------------------- ----------- --------------------------------------------------- Disposal Field (Specify Require ents) -_- ------- " - ---------------- �w ---------------------------------- ------------------------ {yi ...�- -- ---------- - ----------- ----- ........ ... . (Draw existing and required -------------------------------------------------------------------------------------------- r ------------------------------ - - - - ----- ------- 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 become subject to Wor man' Compensation laws of California." Signed ------------------------ --------------- --- -- Owner r-- ✓✓✓ Title _._ Q. t/`i----------------------------------- BY ----------------------------- - (!f other n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- --- DATE s _+--V-7--3---------• - ----- -- -------------------- BUILDING PERMIT ISSUED --------------- ---- -- ------- DATE --------------- ADDITIONAL COMMENTS ---------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------ - - a Date ( f=inal Inspection by: -- '''�� SAN JOAQUIN LOCAL HEALTH DISTRICT WA— Y E. H. 9 1-'68 Rev. 5M