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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------- --------------------- i (Complete in Triplicate) Permit No. _73--96-3 -------------_--------------- This Permit Expires 1 Year From Date Issued Date Issued I Application is hereby made to the San Joaquin Local Health District for a- permit to construct and install the work herein w described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ,� s�,d JOB ADDRESS/LOCATION . -,:- ------------ ----- �-------- - -------- CENSUS TRACT Owner's Name ---- - ------------- - YrL�C�-----------------------------------------------Phone ------------------------------------ Address ---------'5- I6 7 1!57 --- ------------------------ ------ City - _ -. ---------------------------------------- Contractor's Name -- --- -/S_ License # � Yc� Phone Installation will serve: Residence Apartment House ❑ Commercial ❑Trailer Court !❑ Motel F-1 Other ------------------------------ Number of living units:----- Number of bedrooms _______Garbage Grinder ----- -.--.- Lot Size ------------------------------______________ Water Supply: Public System and name .................. ---------------•--------------------------------------------------------------------------------Private Ee Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam Hardpan ❑ Adobe i❑ 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 if public sewer is available within 200 feet,] y PACKAGE TREATMENT [ j SEPTIC TANK'[ ] - Size-------------------------------------------.---- Liquid Depth ____-_- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ -------------- Distance -----Distance to nearest: Well ____________________________________Foundation --------------- ------ Prop. Line __________________-_-6 LEACHING LINE [ No. of Lines ------------------------ Length of each line----------------------._____ Total Length _--______.----------------J 'D' Box .______-'-- Type Filter Material ---------------------Depth Filter Material ___--------___________________--_-.__..-__._ Distance to nearest; Well _______________________ Foundation ------------------------ Property Line __-.-.--.__-______._.___ m SEEPAGE PIT [ ] Depth --------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No �❑ (f� Water Table Depth ------------------------------------------------Rock Size ------------------------------- Distance to nearest: Well ----------------------------------------Foundation ------ Prop. Line ---------------------- 3 REPAIR/ADDITION(Prev. Sanitation`'Petmit# -------------------------------------------- Date ----------.-----------------------) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------- ----------------------------------------------------- D Disposal Field (Specify Requirements) ----- -- r - _ _- ---_ --_ --------------->I------------------------------ --`---Z S ------- - --- ------- - --------- -- - ---- ------------------------------------- ------------------------ ------------------- (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 j 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 P BY " C �-�-- Title ----- (If _ " other than owner) FOR DEP RTMENT USE ONLY APPLICATION ACCEPTED BY --------- --- ------ ------- ---------------- -- ----- ---------- DATE BUILDINGPERMIT ISSUED ------------- --------------------------------------------------------------------------------- DATE .. AL COMMENTS ---------------------------- -------------------------------•---�---•------------------------------ - -- ------------- --------------------•----•-------= i ------------------------------------------------------------------------------------------------------------------------------- ------------------------- ----------- --------------------------------------------------------------------------- ------------------------------------------------ '. ---------- ---------------------------- - ------- ` Final Inspection by: -------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E. H. 9 1-'68 Rev. 5M