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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,:!S-- ------------------------- 0-_----- Permit No: - - -w (Complete in Triplicate) ----------I -------- ----------------------------------- i Date Issued - __" _5Q --------------- This Permit Expires 1 Year From Date Issued Applicatiion 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_ �i� s --------------- ------CENSUS TRACT -------- ------ r Owner's Name a_ ,u -t---' --------- ---- ------ --------- --- Phone �-'- --- CJ :S• - - - -------------------------------------------- Address �� __ � - 2C� ---------------- City. _ Contractor's Name -------- ---- -- -- ---- -- ---- --------License # A . -Yl --- PhoneInstallation will will serve: Residence ❑ Apartment House❑ C/o?mmercial :❑Trailer Court ❑ Motel Other (�"` � T.`er " (/ ? Number of living units:------------ Number of be omsl r Garbage Gri der ------------ Lot Size ___------ ---------------------••--••-•--------------------------------Private Water Supply: Public System and name -__-_-____— ,c.'_____��-�.�� ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK Size-_�f ha s ---------------- Liquid Depth ---�---------------- . Capacity ldlc__ ----- Type P/zPMaterial� ----- No. Compartments -._�------- Distance _-_ __Distance to nearest: Well - ---------------Foundation __. __f---... Prop. Line ____�-_- -_-___ LEACHING LINE No. of Lines ---------f_---------- Length of each line__�0________________ Total Length ._.______._.___ 'D' Box ------------ Type Filter Material Depth Filter Material ------- a_________________________ Distance to nearest: Well _ _U/ttO_ __ Foundation _./<�------------- Property U- 6. t___ ________________ SEEPAGE PIT Depth _ J-----____ Diameter r________________ Number ---------{ -r___ Rock Filled Yes No 0 . Water Table Depth ------ Rock Size -t2'-- ---------------- Distance to nearest: Well -__.----_---Foundation -- d Prop. Line ____ ............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _-.-_________-___-_________.------) Septic Tank (Specify Requirements) ------------------------------------------ - --------------------------------- --------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------R--;-----•-•----------- --------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- ----- --------------- ='_ ' ' (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 th t in the perform ce of work for which this permit is issued, I shall not employ any person in such manner as to bec sub' -Wo an' ompen�o a s of California." Signed -- -------- -- ------- ---- � ------- -- ----- Owner - BY --------------------- -------------------------- �- =--- - -- - Title ------------------ ---------- ---------------------------------- (if ------------ -- - - -- (If other than owner) ' 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------- -------------------------------------------- ------------------ DATE' = ----- _67------------- BUILDING PERMIT ISSUED --------------------------- --------- --------------------- `4Y" <=DATE ---------------- --------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------- --------------- ---------- ------------------------------------------------- ----------------------- --------------------------------------------------------------------------------------------------------------- - --------------------------------------------------------- ---------- ---- - - -- - Final Inspection by: ------ , Date " _SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 1-'68 Rev. 5M.