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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y i -------------------------I--------- --- (Complete in Triplicate) Permit No. ----- ------------ ---------------------------------- - This Permit Expires ] Year From bate Issued Date Issued _ --------------------.--- ----_----------"-----------____ Application is hereby made to the San Joaquin Local Health District for a per 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-4~1aj" JOB ADDRESS/LOCATION --- -a -I �'� ---- 4-----�7- /f G ® � � --CENSUS TRACT ------------------ Owner's Name O y s J_trly-T7-4------------------------------ --------------------------------Phone 'Address . ai"A Q=s�---------- '�---�, f�/F/ / � ---------------- City 7 ----------------------------------------- .. :Contractor's Name __ ,__/,lT'/"dIV __- o/V _______________________License # -- .`�-�� Pftone ----------------- --------- Installation will serve: Residence3E'Apartmen# House^❑ Commercial :❑Trailer Court ',❑ Motel ❑Othe ----------------------------------- -•------ Number of living units------ Number of bedrooms _'_______Garbage Grinder ------------ Lot Size __3.5�'! G s .__-.___.< i E Water Supply: Public System and name --- `; -------------------- -----------------------------• -----Private a Character of soil to a depth of 3 feet:_ Sand'❑ Sit❑ Clay ❑ Peat❑ Sandy Loam pf Clay Loam 0 Hardpan ❑ dobe-0 Fill Material ------------ If yes, type _(Plot plan, sho ing size of clot, 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'[ ] Size------------------------------------------------ Liquid Depth -------_-_---- - Ca acifi P Y ----------------•--- Type -------------------- Material --------------------- No. Compartments -------------.........x W Distance to nearest: Well -----------------------------� ---Foundation ---------------------- Prop. Line ------------- LEACHING --------- -LEACHING LINE [ ) No. of Lines _______________________ Length of each line J_-____________-____._-____ Total Length �_ __ -------- - ---- 'D' Box ------------ Type FilteriMaterial ____________________Depth Filter Material -------------------- ------- ----_Distance'-tb nerfrest'Mll------------------- Found ati:on ------------------------ Property Line ------------ -------- SEEPAGE PIT [ ] Depth ------- Diameter ___ _ Number1__________________________ Rock Filled Yes F] No .i❑ , c7ter Ta61e peptly.---- = ---------------------Rock Size ------------------------ ------ stance-to..nea est: Well ----------------------------------------Foundation -------------------- Prop. Line -------------?.....-.- REPAIR/ADDITION(Prev. Sanitation Per it# -------.------------------------------------ Date ---------------------------------_} SepticTank (Specify Requirements} ---I ------------------------------------- --------------------------------- --------------------------------••----------------- � ------ Disposal Field {Specify Requirements) _______ __ _ - _�� -e9_G_ ?_-_------------------------------------ --------------------------- ---------------------------------------------------------------------------�,4., je/V syS7e N) ------------ ------ --------------- l _ I" (Drayv existing and required addition on reverse side) FL 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 ,Ruh Rules and Regulations of the San Joaquin Local Health District. Home owner or Ficen- set! agents signature certifies the followi g: "I certify that in the performance of theork for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Comoonsation laws of California." 1 Signed _.__�,..- ---�-�------- - - - �-!-___4571P-�---------------------------- Owner I BY ----------- --- - ----- k-- ----- ------------------------- ----- Title -------------- (If other than ow I FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY --- ---------- ---i------------------------------------- ----------------------------------------- DATE ------------------------------------ ------ BUILDING PERMIT ISSUED --------------'------}-----------------------------------------------------------------------------------DATE -- ---- -------------------------- I------ ADDITIONAL COMMENTS f ------ --------------------------------------- ------ ----------- ------------------------------------------------- - - -- -------------------------------------------------- ------------------------------------ ------ ---------------------------------------- -------------- --------------------------------------- ' ------------------------- ---------------------------------------'--------------------------------------- - Final Inspection b z-------------------------------------- Date _ ��--�-�------•-----=------- �AN JOAQUIN LOCAL TH DISTRICT S E. H. 9 1-'b8 Rev. 5M. 0� ]