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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (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 in©�w the work herein2,,z— described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: -= ------CENSUS TRACT ------------------- ------ Owner's Name -�-� --�---�-- --- ----------------------------------------_--------:- �------- --- --- JOB ADDRESSAOCATION .-----_---- l w':•-�:.1�4=4�✓ -----=-=-------------------Phone Address --------_ r_.__1ii1�-----�/1� �. Cit i ---- ------------ Phone ,r`/ Contractor's Name __ - `' L�44w/ /�if� Installation will serve: Residence Apartment House❑ Commer al: ailet Court ourt i❑ Motel ❑Other- -'------- = . ------- ---- Number of living units:._. _____ Number of bedrooms �'______Garbdge Grinder ------------ Lot Size 't_------- ----------------------------------- Water ___________________ __ � ------------------- Water Supply: Public System and name _______ ---------------------------------------------- I ------------------------------------------------------------_-------Private Character of soil to a depth of 3 feet: Sand' ❑ Silt❑ Cla y ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe'❑ Fill 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 septicI itank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ SEPTIC TANK Al Size__, -$~------------- Liquid Depth _7--------- ..� 1 Capacity _,,,z._0_-1D___---- Type �/Lc- J -:- Material- ----_ No. Compartments ___________ Distance to nearest: Well ------------------------------------Foundation ---------.------------- Prop. Line -----------------_---_ LEACHING LINE [ ] No. of Lines ---------------- Length of each line.__J0&------------------- Total Length --•----------------- 'D' Box4�_. __ Type Filter Material/rJ_•__I'-----------Depth Filter Material 4*0_� Distance to nearest: Well -_.____---------------- Foundation __-_._--__ ._ Property i 4 Pro er Line _.__-____._ SEEPAGE PIT [ ] Depth .-- t______________ Diameter ---------------- Number --------I--,_ Rock Filled Yes ❑ No I❑ Water Table Depth ---------------------------------------`0•----Rock Size ---- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ....._-------..----_-- REPAIR/ADDITION(Prey. Sanitation Permit# ________.___ ------ __________________ Date _______ ) Septic Tank {Specify Requirements} -----------------------------=-------------------- Disposai Field (Specify Requirements) -------_---------------------- ----------------------------------------- -----• --------- ------------------ - - - ---------------------------------------------------- (Draw existing and required addition on reverse side) 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. Home owner or licen- sed agents signature certifies the following: "I certify That a the performance o as to beco a subf the work for which this permit is issued, 1 shall not employ any person in such manner 'ect.to Workman's Compensatio ws of C .!i Signed rnia." ti {I of er than owner] � � . � i `i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- --------------------------------------------------------- ------------------ DATE _ 77/4 __`� BUILDING PERMIT ISSUED -- -- -------------------------------- -------------------------------------------------- ---DATE --------------- 4 TIONAL COMMENTS ---------------I - --------------------------�-- ------------�----- � --------------_---------------------------------------------------------------- --------------------------- --- - --------------------- ------------------- --------------------- -------- -- Final Inspection by: .___ Date 'r_ " _e ---------- ------------------------- - - - --- ----------- - --- ----- ---- - -- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT �f E. H. 9 1-'68 Rev. 5M