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- FOR OFFICE USE: w 1;3 APPLICATION FOR SANITATION PERMIT-------------- �� ------ --------------- � (Complete in Triplicate) Permit No. � ----------I---------------- ------------- --- ______________________________________--------------- This Permit Expires i Year From Date Issued Date Issued ---7=3----J--7 Application is hereby made to the San Joaquin Local Wealth 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 _r -. %� �1� --------------------------------------- Phone - Y 2 3------------�.- `! Address ----'7 3---F---7-- {�!_N1001 i ------- City k - a -------------------------------------------- ------------- -----------------------------------•------ Contractor's Name ____ __. _ fi __ __ _ �1 _----------------_-------License # _ 391 r Phone Installation will serve: Residence ®Apartment House^❑ Commercial ❑Trailer Court i❑ t ` Motel ❑ Other -------------------------------------------- Number of living units:_./_------ Number of bedrooms _,_____Garbage Grinder - ---------- Lot Size _- (ie, Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ I (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) i NEW INSTALLATION: (No septicitank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ I Size_ ____ :__ _"?___/TI Z� _ � Liquid bepth _ '_____________ Capacity _ ----- Type _ 'yI__ Material_f No. Compartments ---------_ - I Distance to nearest: Well -___.___s _ _________________Foundation _____� _________ Prop. Line J_--------------- LEACHING _____________LEACHING LINE [ ] 'No. of Lines ------- g ----------------------- Length of each line --- _ -- Total Length -&6-------------- 14 'D' Box __ Type Filter Material fa_� Depth Filter Material ___/_ ________�___ ______________ j f � 00 Distance to nearest: Well _____ ? _________ Foundation ______- ---------- Property Line _;�____________________ SEEPAGE PIT [ ] Depth _ __ _______________ Diameter ----------------- Number ------------------- Rock Filled Yes ❑ No 0 1 I; Water Table Depth ------------------------------------------------Rock Size ----=----------------- Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ...................... ; REPAIR/ADDITION{Prey. Sanitation= Permit# _________________________ -------.---------- Date _____________-____________________) � SepticTank (Specify Requireme its) -- - -------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) -------------------------- ------------------------------------------------------------------------------------------ ---•-•------- --------------------------------------------------- ------------------------- 1. - (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, I shall not employ any person in s ch manner as to become subject to Workma 's Compensation laws of California." Signed --- --- - ------ -- ---------- - : ` Owner BY -r=--- ----- --- - --- ---------- Title ------------------------ ----------------------------------------------- f (I other than owner) FOR- DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ ----------------------------------------------------------- DATE ------�-------- ------ ......--------- BUILDING PERMIT ISSUED __----------I---------------------- ------------------ / -------------------- DATE - f ADDITIONAL COMMENT--.---d��1�—, .''-r'c"'-_ "`r. -'---�Le----- -�-a,1 + Go�-F�',.-�.ra_--•-------------------- ----------- --------------- -------�`----- r--- -- ----- --------------------------------------------- i '� - - ------------------------------------------------------------------------------------------- ---- Final Ins ection b Date _.' P y - ----- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. SM