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FOR OFFICE USE: /G. N0-v- K" APPLICATION FOR SANITATION PERMIT --------------------------------- -- 7 - y (Complete in Triplicate) Permit No.. ---------------------. ---------------------------------------------- ___._.________.___ This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION -- q �Q SCJ0 ------1_�D,--------- ------- ---------- -------- -CENSUS TRACT -------------- ----------- Owner's Name -------------------- - - -- ----- -` Phone Address Contractor's Name ----------- - � ----------------------------------------------------- License # ----------- ----------- Phone - --------------. -------- Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ER-Other ---- j'L------------- Number of living units:_._ - Number of bedrooms ----- __Garbage Grinder ------ Lot Size _____-4---------------------------------- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam El Hardpan ❑ Adobe' ill 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,) I v! PACKAGE TREATMENT ( ) SEPTIC TANK![� (� Size---------f_r?l --- Liquid Depth __Z/'L_____________ 04 ) Capacity _J ------ Type l�Ia2a __--- Material - -_-_ Na. Compartments ...... Distance to nearest: Well -----/'Zb_.................... Foundation ---------- Prop. Line ----- __...:......_ LEACHING LINE [ ] No. of Lines ------0? Length of each line------------7U__._----- Total Length ____l __..__.. - 'D' Box _ it?:g__ Type Filter Material _&----Depth Filter Material -_____lcl' i Distance to nearest: Well __lq6_____________ Foundation --------40---------- Property Line -----S_"]_______-_-.-. SEEPAGE PIT [ ] Depth ___________________ Diameter ________________ Number .____..__ ------ ----------- Rock Filled Yes ❑ No i❑ Water Table Depth ----------------------------------------------Rock Size -------------------------------- � Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ......_____._____ REPAIR/ADDITION(Prev. Sanitation Permit# ---------- _________________________________ Date _______________-_--_-_____________) i SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•---- -----------------------••-------------------------- Disposal -------------------- -..Disposal Field (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. Home owner or licen- sed agents signature certifies the following: "I certify th=otherthan ormance of the work for which this permit is issued, I shall not employ any person in such manner as to becomorkman' enation laws of California." Signed _ ---- g - - -------------•------------ Owner 11 By -------------- ------ ----------------------- Title ----------- --- --- ------------------------------------------------- an owner) k FOR DEPARXMTgSE O LY% -7 i APPLICATION ACCEPTED BY -------- ------------ ----- ---------- = DATE ` � - / BUILDING PERMIT ISSUED i --------------- --- ------- -- -- -----------------------DATE ------------------------------------------- ADDITIONAL COMMENTS --------------- ---------------- ------------------------------------ ------------------;---------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------- --- . _ . % _ --- Final Inspection by- _ Rato `---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1-'68 Rev. 5M