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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT = ..w V. ;ti � ,.F Permit No,. (Complete in Triplicate) ---------- ---- - -------- ------- _-_ This Permit Expires 1 Year From Date Issued Date Issued --- --------------------------------- Application is hereby made to theSan 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/LOCATIpN .---Z2y - lv!,_.1 ---Gi��rrJUzC�___Q.!/� _----� " _�`�`"`+------..CENSUS TRACT --------------- Owner's Name lam_ R< rOS " 1�'I _r --- +� -Phone Address -- ---� ----------------- ----------------------- -`-- Cit Y�� 1��--------------------------------�------------- Contractor's Name _-- _ ...-- PU._ _ _-- Oft-----------------------License #--W_ 1 1 T-Q Phone ?`_ ----_- � _ Installation will serve: esu ernce_ Apartment Ouse Commercial:�gTrailer.Court ;❑ } / I Motel ❑ Other -7 eve__ _ ,"O' .a �f Number of living units_____________ Number of bedrooms :___________Garbage Grinder _.___- Lot Size - ?--Tl.-C--- ___ --- Water Supply: Public System and name ( C �[----�,�v-a -- �-Y- ----------------- ;------------------------------------Private ❑ Character of soil to a depth of 3 feet: SandE] Sift F) Clay ❑ :Peat❑'�a Sandy Loam -M Clay Loam Hardpan ❑ Adobes 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 ifzpublic sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK Size____ Liquid Depth ... r - Capacity J- -____-- Type/-C- C3�Mate;.ial-- /��Y--- o. Compartments __ ...-.-•r---.. Distance to nearest: Well _______ ________________ __`3_-.-Foundations_______ Prop. Line ____ _:________ LEACHING LINE [�j� No. of Lines - Length of each line. Total Length ___�._ Q_-- . --- - -------- D' Box - ---------- Type Filter Material ---Depth ilter Material --l-- ------------------------------ Distance to nearest: Well _____ .__��~________________ Foundation L( --._---_--__ Property Line ___- ...... SEEPAGE PIT [ ] — Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size ------------------------_-- f Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ______----_------_-------------------------- Date __________________-______________} SepticTank (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 Son 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 " t e performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to becom sect to o an's Co nsat'i.on ws of C '' ornia." Signe ---------------------- -- -------- Owner BY ------- = ------ Title --------------------------------- ----------- -- --------------------- --- ---------------- --------------------------------------- ta FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- DATE ------ BUILDING PERMIT ISSUED ------- ---------- - ----------------- ---DATE -- - ------- ------ ADDITIONAL COMMENTS --------� -------- - -- --------------------- ---- ------------------------------ � S- _ --------------r------- Final Inspection b _____Date _- P Y: ---- - -- - - --------- SAN J AQUIN LOCAL HEALTH DISTRICT ' E. H. 9 1-'68 Rev. 5M