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-ti FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT ---------------------- ------- -- Permit No. �-C -r--1-'-�- (Complete in Triplicate) ----------------- -------------------------------------- Date Issued _____________________________i __�_____ This Permit Expires 1 Year From Date Issued 7 -/07S 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 .--.��- - e/'" -----------------------------------------------CENSUS TRACT -------------------------- Owner's Name -- � (f', Ff2 - Phone Address ------ -------=--=------------------------------------------------- City ------------ -------------------- ---------------------------------- Contractor's Name � df?i_-„�_� -----------------------------------License Installation will serve: Residence;°Apartment House❑ Commercial ❑Trailer Court I❑ { Motel ❑ Other ---------.---------------------------------- O Number of living units:______ Number of bedrooms _____Garbage'Grinder _ Lot Size --' _____________ Water Supply: Public System and name --------------------------------------------- ---------•-•----------------------- ------------Private Character of soil to a depth of 3 feet: Sand'❑ 'Silt C] Clay ❑ Peat❑ Sandy Loam ❑,/ Clay Loam ❑ r f f Hardpan ❑ Adobe k Fill Material ------------ if yes, type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r J PACKAGE TREATMENT [ I SEPTIC TANK a Size___ . Liquid Depth ___________._.. OQ Capacity/ _�___-__ Type/4P/ ___ __ Material_ /. ' "_ No. Compartments ___ --__.......... W Distance to nearest: Wel! ----- ? �_______________Foundation jj_.. _�___ Prop. Line __ �_�_.._. r LEACHING LINE r'' No. of Lines - 7-------------- Length of each lineF��__ Total Length le!�_ ---------- 'D' Box/ACIF Type Filter MateriavbllirAepth Filter Material., ` _______________________________ Distance to nearest: Well --- `'-----_- Foundation -----Jf_'li _` e--__.__ Property Line ___ __�_.....___ 14 SEEPAGE PIT Depth -�$ __ _____ Diametet>""___"�__ Number _______________ __________ Rock Filled Yes " No i❑ lo, a r �- Water Table Depth ___- ��~ Rock Sized _VP le -- "Distance to nearest: Well --- ------------------------------Foundation --- �_-___ Prop. Line .. ..__.._..... REPAIR/ADDITION(Prev. Sanitation Permit# _____-_- ______________________ Date ---------------!-A---------------- Septic _________J Septic Tank (Specify Requirements) --------------- --------------------------- Disposal 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 in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of Caiifornia." Signed - ----- ----- ------- Owner --------------------------------- BY ----------------------- -- -------- - `-------------------------------- Title ---- - ---------- ------------ (If er than owner) 1 .1 P it FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY " -------------- ----------------------- ----------------------------------- DATE ... �'I 1 ------------- BUILDING PERMIT ISSUED ---- ----------------------------- ----------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------- ------- = ----- ------------------------------- ---------------------------------------------------------- ------------------------------------------------------------- ------- ---------------- ------- ----------- ---------- ' ---- ------------------ ----- ------------------------------------ ----------------------------------- -- - -- - ---------------- Final Inspection b �. ______.Date ___-_. ____�.___..___. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev.,5M,1 ,