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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT V a 79 ---------- --- Permit No. --- a-�- - ------------------------------------------ - ------- --------------- (Complete in Triplicate) I - ----- ----I--------------------- Date Issued This Permit Expires 1 Year From Date Issued- - 1 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 main compliance with County Ord ina a No. 9 and�^e��ry'stin Ryl�s`ran�Regulgtions: - � V-t=Q1�. ice/ _. - CENSUS TRACT JOB ADDRESSAOCATIO y; _- __. I� Owners Name --------- ---------- -- --------- ----=-=------- - ---=--Phone --I`------ -----------------•-------- -- •---- Address City --------------------- I� --- ---- ----------------------- --------�---- ---�----- / Contractor's Name -----__-,? - -------.License ----- Phone Installation will serve: ",,Residence ❑ Apartrge House'❑ Commercial ❑TXaile, ;E:],Court ; 'Motel ❑Other k Number of living units-------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---------I---------------------------------- Water _ ________________________ 4 _ _ II Y - - - - � � Clay Peat Sandy Loam -•---------------------Private ❑ Water Supply. Public System and name -- -- ----•-------------------------------------- ---------- Character of soil to a depth of 3 feet: Sand❑ ,Silt[]- y ❑ ❑ � Clay Loa Hardpan ❑ I Adobe'❑ Fill Material ------------ If yes,type h�----- ----- (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 p permitted.if public sewer is available within 200 feet,) I ir :, il. PACKAGE TREATMENT SEPTIC TANK.[ j Size-------- ------------------------------------- Liquid Depth -------------------------- Capacity ------------------------- p Y ---------------- Y - t Ca ,cit T 5 e ------------ Material No. Compartments Distance to nearest: Well— --=-- -- =-----------------Foundation ------------------'- Prop: Line ...... --------------- Distance of Lines':-:--- ------ Length of each line---------------------- ----- Total Length'r--"---:'---_ LEACHING LINE [ j .1 k_ f 'D' Box ------ ----- Type Filter Material --------------------Depth Filter Material 1-= 11 '---- Distanceto nearest: We!! : Foundation ---------------------____.--_____,__-..___ Property Line y SEEPAGE: PIT [ ) Depth ----- --------�-__. Diameter ---------------- Number ---------------------- ----- Rack,Filled Yes El No ❑ 4 Water Table Depth ------'------` ------- -----------------••..Rock Size --------------- ; -. Distance to nearest: Well ------------------------------Foundation -------- ------ ---- Prop. Line ------•_---•--------_ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _-___-._______--------------..----1 j Septic Tank (Specify Requirements) -------------------- ---------------------------------------------------------------- - ------------------ Qisposal Fi Id (Specify Require nts) �. -------- C� C) 61 . = _. = 77-1i -- i--- -- --- --- -- - (Draw existing and required additi n on reverse side) il 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. Flame 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 Workman's Compensation laws of California." fSigned ----_-- -- t --------•-------------------- Owner BY ---------- -- ------- - ------ ---- -- ----------------- ----- Title ----------- ----------------- ---------------------- ot than owner} FOR DEPARTMENT USE ONLY ------- --------- DATE ------lil,?---------------- --------- APPLICATION A CEPTED BY �I__- �` -------- DATK- �( ---•--- - - f BUILDING PERMIT ISSUED -___ ----- -------------- --------- : ADDITIONAL COMMENTS __-_'--- -------- - --- �[ d �[.�.ie^-L� - -- r (l ---------------- - a ._ f ------------------ -- L.----�-�_ ----------------------------- - --------- ------------------------------------ ------ ---- --te_;-------------------- ---------------------------------------------------------------- - !I- ----------- ----------- --- ------- ---t- � -�-�----� = Final Inspection bY: ---------- Date _ ` SAN JOAQUIN LOCAL HEALT DISTRICT ] ` E. H. 9 1268 Rev. 5M I {.