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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / --------------�--1•--�'��G- tr 'k2 Permit No. 14 (Complete in Triplicate) ------------------------- -2 - Y This Permit Expires i Year From Date Issued Date Issued 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. r --- -----CENSUS TRACT -------------- ----------- JOB ADDRESS/LOCATION - ----� .� - :-—Gly-- Owner's Name ---- --- ''1=----------------------------------------------------------=- -----------------_Phone ------------------------------------ Address -------- -- --------- j----- ------^-------- -------------------------- ------- --• City ---------------------------- ------- Contractor's Name-------- ----`�\ T --------------------------- ---------License # -1778'n----- Phone --------------------------- t Installation will serve: Residence ®Apartment House-[] Commercial ❑Trailer Court Motel ❑ Other ------- ------------------------ Number of living units:-_-_ Number of bed rooms _2,:--___Garbage Grinder!-_.-__ Lot Size ---------------------------------------- Water ________________ _----____-_______--_-Water Supply: Public System and name --------- ---"` ---------------- -------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑_ Silt❑__ _Clay ❑ Peat❑_ Sandy Loamy❑` Clay Loam ❑ Hardpan ❑ . Adobe [Fill Material ------------ If yes, type _________________------_.- r (Plot plan, s,,gowing size of lot, locationtof system in relation to wells, buildings, .etc. must be placed on reverse side.) r ' NEW INSTALLATION: (No septic tank o seepage pit permitted if public sewer is available within 200 feet,) W m ON) "Size------------------ quid De th - PACKAGE TREATMENT [ ] 'SEPTICaSANK`'['] r� __- Li p Capacity =------------�. Type -------------- -- Material-------------- ------- No. Compartments ------ Distance tc nearest: Well __________________-_-__Foundation - -------------------- Prop. Line ________ LEACHING LINE [ ] No. of Lines.;:__,--------------------- Length of each line---------------------------- Total Length -____.....__._.__ 'D' Box --------- Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nea est: Well -- --------------------- Foundation ------------------------ Property Line ------------------------- ' SEEPAGE PIT J Depth _`'� Diameter ---------------- Number --------------_------------ Rock Filled. ❑Yes No 0 ' Water Table Depth'.,' ----------------------------------i-----------Rock Size ------------''-------- ---------- Distance to nearest: VVell—i!�'--------------------------------------Foundation --------------- ---- Prop. Line --------------------- REPAIR/ADDITION _________________ _REPAIR/ADDITION(Prev. Sanitation Permit# _^ p - Date ---------------------------------- Septic _______< _______________________Septic Tank (Specify Requirements) __ � a _•• aIt ��f ----•- 1 Disposal Field {S ecif Re uiremerits) -------------------- ------------------------------------- --------------- ------------ ----------- --- --- w------- ------------------- -'------- (Draw exisfirig and required addition on reverse side) I hereby certify that I .ha a prepared thisapplication 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." I Signed ____.__ -_ I ' 'Owner $Y - ---- ------ ------ ----- ---------------- Title ----------- ---- ------ - ------------------------------------ (If other'than ow ed FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------------------- DATE " �= BUILDING PERMIT ISSUED `- `:' - �"' -- - w----�`--`-- `�---------- `" "-'-DATE -�. ------- ---------------------------- ADDITIONAL COMMENTS -7_L-6 -- •rid--� _--•_�________�------------ -------- -- --------------- ---------------- ------------- -------- - ----- ---------------------- - --> FinalInspection by: ------------------ -------------------------------- - .-- --------- --------------------------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT. t E. H. 9 i-'6$ Rev. 5M