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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ---------- ---- ----------- Permit No. (Complete in Triplicate) = t f Date Issued _= ------------------------------------------------- = 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/LOCATION ------------------------ ---- CENSUS TRACT -------------------------- Owner's Name -,e —------`maq,&*---------------- -------- ---------------------------------------------Phone ------------------------------------ Address 9;-Ir -4.W-l{ City - - - Contractor's Name ---.License #20`W '3--- Phone Installation will serve: Residence ❑ Apartment House ❑ CommercialArailer Court ',]] Motel ❑ Other -------------------------------------------- I „_— Number of living units:___________ Number of bedrooms _--_---_----Garbage Grinder ------------ Lot Size - _--- ------------------ i77 _ Water Supply: Public System and name -------------------------------------------------------------- - •---- -------------------PrivateX Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ k Hardpan ❑ Adobe`< Fill Material ------------ If yes, type ------------------------- (Plot ---_ __(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse :side.) \(� NEW INSTALLATION: 1No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ---------------___--.. --. Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---- ----•-•---------- Distance to nearest: Well ------------------------------------Foundation ---_-'�'----- Prop. Line ---------.-..---_--- LEACHING LINE [ ] No. of Lines ------------------ ---- Length of eachline---------------------------- Total Length -----------.-__.-__--_------ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------__:-----_.-_---_-.-. ---_.._._.-- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --__---_-----_-_........ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to.nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..---_-_--_-_-_-.--_-- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date __-_-_-.---_------_-_-_-_--_-----} Septic Tank (Specify Requirements) ------- -------------------------------------------------------------------- ------------- ---------- - - ----- -------- _ee i, • ' Disposal Field (Specify Requirements) k`--.�{a?--- --,_ _, __,�_Q_ _-----. -------- s (Dr existEng and required addition on reve'r side} I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin j 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, 1 shall not employ any person in such manner as to be e s bjectjo or an's Compen ' n laws of California." Signed --------------- -- - - ---------------- ------------------_ Owner BY ------------------------------ -- ----- , -------------- Title ------------------ ------------------- ---------------------- (If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------- DATE ,g. .. BUILDING PERMIT ISSUED --- _-- ----DATE ------------------- -------------------------------------------------------------------------------------------- ---- ADDET AL CO ENTS 4 - - - - - - - -- ---- - -- ------ - --- - - - --- -- ----------------------------------- t Finalnspection bY- ----------------------------------------------------------------------- ---- ----------- --- ----------------.Date ----------------------- SAN JOAQUIN LOCAL H RICT E. H. 9 1-'68 Rev. 5M