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N s FOR'OFFICE USE: APPLICATION-FOR SANITATION PERMIT Permit No. -�y ----- ------- -------- - (Complete in Triplicate),f" - ---------- p i Date issued ------------------- This ------------ --- -- - This Permit Expires 1 Year From Date Issue d V ------------- ------------------------------------------j 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 .---L- _p_ j14tE_�uti CENSUS TRACT --r � , Owner's Name )F-t'-N Q - -------- Ph°fie �- - J�� Z--------`j ; Address Phone ----------------------------- Contractor's Name .----------j------------------------ --gezf e # Installation will serve: Residence i partment House❑ Commercial ❑Trailer Court ,❑ MotelF1 Other ------ ------------------------------------- =- Lot Size------------------- ----------------------- Number of living units------------- Number of bedrooms ___________Garbage Grinder ----- -----------------Private ❑ Water Supply: Public System and name ----------------------------------------- --------------------------- ---- ----------- Peat Sand Loam ❑ Clay Loam ❑ Character of soil to a depth of 3 feet: Sand❑ Silt ❑ CI,E, q� """"�, Y .� Fill.Material---""-`-if yes,'type ------ --------------------- Hardpan ❑; , Adobe -Fill. , v4 Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) [ p � NEW INSTALLATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] ize_------, --_-_--,-:- - =;�, :�,L,auid Depth ------------------ - _• Material--�--------'- �c � Na. Co partments -----------------•---- ,. Ca acit _ _ Type ----------- ---- - p Y ----------------- Distance to nearest: Well ------------ ---------------------- Foundation -------- Prop. Line ----------------••-- - Total Length Lent of each line--------------------------- 9 ------ --------•---- LEACHING LINE [ ] �No.'of Lines _______________________ g -------- CV Box ------------ Type Filter Materiel ______-------------Depth Filter Material ------------•---••---- c Foundation --------- Pr perty Line ------------------------ W`Distance to nearest: Wellk_•-_._- -- x Ro k Filled Yesk[] No C) SEEPAGE PIT [ ] Depth Diameter----- ---------- Number --------------- � t Water Table Depth ------ -------- -------------------- Rock Size ---------- n o -------Foundation Prop. Line - Distance to nearest: Well ------- - - ------------- , � ti REPAIR/ADDITION[Prev.. Sanitation Permit# ------------------== ------------------ - Date ---------------------------- - -- ' r----------------- Septic Tank (Specify Requirements) -------------------- ----------=;- Disposal Field (Specify' Requirements) --- --------� i-# -t-N��___ " VA-4-A-19' X17~ V ---------------- ---------•----•--------- -------------------- - \ ' --------- -* y- --------------------------------------------------- ------- €° '' -------------------------------------------- '-- �4 (Draw existing and requirediadd'ition on reverse side) I hereby certify that I have prepared this application and that\fhe 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 rtertifies the following: "I certify hat in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to b c subject10 an' Compensation laws of California." Signed t Owner / , ' Title ------ -------------------------------------------- BY -- ------- ---------- -------- ------------------------------ --= - (1f other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 18Y ._. '_.to --------------------------------------------- DATE �� ------ -------- ----------- ------ DATE -_ BUILDING PERMIT-ISSUED = �,�.._. ,w ,,-�, �. . --.- ------ ., . ADDITIONAL COMMENTS ,. -- - ------------------------ ,4 -----------�--------- - - - - ------- - _N, s - -------------------- --- ------------------------------ Final Inspectio ----- ----- --------- ------ - ----------- -Date I SAN JOAQUIN L(TCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M