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FOR OFFICE USE: I" 6 3 APPLICATION FOR SANITATION PERMIT -------------------------------- �V (Complete in Triplicate) Permit No: -------- --- ------------ ------- -------------------------- __---------------__----- - This Permit Expires i 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 .--._ 7 -----F,------0{-1_}4(�G-�----------------------------------CENSUS TRACT -----`-�_- -- ---- . - Owner's Name Lj3 _' � 5► --------------------------------------------- Phone '`d ��--------------------------------- Address f1 _ _. _.City-__ -------------- - ��.ISL-Q-n�_-�-------------------------••----------- Contractor's Name ----104/�1-1j- ----------------------------------------`------- ------.License # ---------.--------------,Phone --------------•--------------- Instailation will serve: Residence ❑ Apartment House❑ CommercidL❑Trpiler Court '❑ I . / Motel 0 Other -- ---- Number of living units:----.[_..__ Number of bedrooms ----�rGarbage Grinder --_- Lot Size -__A-CAF- C - :.-_._---_.-. Water Supply: Public System and name ----------------------- -- = - - - - -- Private --------------------------------------- Character of soil to a dep th,of 3 feet:..__Sand'❑ Si Cla"y ' ❑ Peat❑ Sandy Loam ❑ Clay Loam - Hardpan 4 Adobe ❑ Pill 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 see age pit permitted if public sewer is avoilab a within 200 feet,] NJ PACKAGE TREATMENT { ] SEPTIC TANK.[ I '� Size------"I-----------------'----E---_-------- -- Liquid Depth --------------------- ---- � s Capacity �. pe ------------'' .; Materidl±{ -"'5---- ------ N Compartments ------• ---•------•--- Distance to nearest: ell ---------------------.,---------_-Foundation -----_- ___-----_- Pro Line .------_-_-_-_-......_ - p• LEACHING LINE [ ]' bo.B Xliri-e�s ---'-rYP�v ilter�Material of 'eaech�ineDepth e tF�---Filter Ma eralal Length----------------------------- + g f p --Distance to nearest: W II ------------------ --`- foundation ------------------- ---- Property Line -------------------_.-., SEEPAGE PIT [ ] Depth -------------------- D ameter __--_--_--_-1: Number ----------------------- ---_ Rock Filled Yes ❑ No C] ' Water Table Depth -----------------------------------------Rock Size ------- - ----------------•---- Distance to nearest: ---------------------- -----------------Foundation ---- -------- ---- Prop. Line ---------------------- ' REPAIR/ADDITION(Prev. Sanitation Permit# --- ;•- ----------------------------------- Date ----------------- -------___-----) Septic Tank (Specify Requirements) ------------- - - ------------------ Disposol Field (Specify Requirern$nts) ---- _-- ----- -_�_r�--------------� {� `} ------- 1' ----- ----------- --- ----------- X-� Z?i - - -- Et --------- --•--E..-.�_:.,-- - - ---,_., i-----------------'_--- .-`--------------_---- -�----- v .f �`VDraw a listing and required;addition on reverse side) - r 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. Nome owner or licen- sed agents signature certir'e the following: , "I certify th i th rfor an f t work for hick this permit is issued, I shall not employ any, person in such manner I as to beco bi c o W km laws of California." Signed ---- Owner BY ---------- ------------------ ----------------------------------------- ------------ 'Title ------------ r ---------------------- (If other than owner[ -------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------t(A_C9 ------------- DATE -._ .- _- -'- _ ---------- BUILDING PERMIT_ISSLIED __---.------,-------•----... DATE ADDlfIONAL COMMENTS 1-�- �1 n ---- ---------------------- ---- - ----------- 1 ---------------------------- --- Final Inspection by ------------- ------------------- ---- ---------- ------- ---- ----- -- - - ---- --------------- --------------------------- / ------------------•-----------•---------------------------------------Date -------- �e SAN JOAQUIN LOCAL HEALTH DISTRICT r`ti 4 r' --E. H. 9 1-'68 Rev. 5M