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FOR OFFICE USE: APPLICATIOW'FOR SANITATION PERMIT -3�--` (Complete in Triplicate) Permit No: - --- -------------------------------------------- ---------------------------------------------------------- This Permit Expires ] Year From Date Issued Date Issued __y/ --- 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 CountyOrdinanceNo. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .-GD'jM�rvf G�� /y l- i�d Wi, ,6 r,;-, - - - -- -----------•------ --------CENSUS TRACT Owner's Name -._G.c.�c�- --- G. 4---------` ma c- ic_�' M�" �•� �,a 7----------Phone .-ffG Address ] -6 - Cit Contractor's Name --9 --.0 12 ��,Alg�� - ------ -------- -- _.License # ------ ----------------- Phone -`i_'`lG-Ea-a�'f_-•- Installation will serve: [X Residence Apartment House�❑ Commercial :❑Trailer Court ❑ Motel ❑Other - --------------------------- -- Number of living units:_._-?J--- Number of bedrooms -_ -_-- .Garbage Grinder _Y�� Lot Size Water Supply: Public System and name G��nrr w�_ � ,� ��x.�,,t G4t_,t �p �� , --- 4 Private ❑ - Character of soil to a depth of 3 feet: Sand& Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ f l Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type -__---__.----__----_ ----- I (Plot plan, showing size of lat,E 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' ls_Q -.--Gr-r'p_ Liquid Depth Capacity -�f �.a. Type Mo„srn Material- `'''�'�•' No: Compartments e------------ Distance to nearest: Well _ '_ o--------------------Foundation ---------------------- prop. Line ---------------------- k LEACHING LINE [ ] No, of Lines --___------------------ Length of each line---------------------------- Total Length 'D' Box ----------- Type Filter Material --------------------Depth Filter Material ---- --------- ----------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line EPAGE PIT [ ] Depth -------------------- Diameter ---� ----------------- Number ----------------- ---------- Rock Filled Yes [] No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------------•- -- Distance to nearest: Well --------------------------------------- Foundation --------------------- Prop. Line ---_----------_-_ PAIR ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------•------___-- } --------------- Septic Tank (Specify Requirements] _.---___--- isposal 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." + Signed � - -- ---- Owner --------------------------------------- BY ----- ----------------------------------------- (If - ----- Title ------------------------ ------ - (If other than owner] ---------- --------------------------------- a FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -- --d_----,-____-- DATE - -I - BUILDING PERMIT ISSUED - ---------- ------------------------------------------ -- -------DATE ADDITIONAL COMMENTS ------------------ ----------- --------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- ------- - ------------------------------------------------------------------------------------------------------ y Final inspection by: ----- - - Date ---------------------- ft-- - - ---- -- - - ------- -- -- - -------. ---�- - - - - - - - - - -- - - SAN JOAQUIN LOCAL HEALTH DISTRICT ��;,� E. H. 9 1-'66 Rev. 5M �