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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT Permit No.. --------- ------- --� -- --------------------------------•----------------- - - (Complete in Triplicate) d IDate Issued -------:-- �M This Permit Expires 1 Year From Date Issue Application is hereby made: PP 17L the'San Joaquin Local Health District for a permit to construct and install the work herein Regulations- described. This application is made in compliance with County Ordinance No.w 549 and existing Rules and Regulafiions: i -----------CENSUS TRACT JOB ADDRESS/LOCATO Phone - Owner's Name -- ----- -- City -- ---------------------- Address ----------- YA - ' "=-'-- -------- -• --- --License # 1�� Y �- - � ---- ---- hone ---- ------- ----------------- Contractor's Name -- ------ - -- - -` _ y ailer Court ❑ Installation will serve: - Residence LeApartment House❑ Commercial ❑Tr �. Motel ❑Other -------------------------------------------- Number of living units:- �_"--- Number of bedrooms --3-----_Garbage Grinder ------------ Lot Size ----- Private, an nam __"----------- -------- -----------�-- - -------------- Water Supply: Public OYSIel:l Csoil to a depth of 3 feet:- Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -E] Clay Loam ❑ Character of y e ----- --------------- - Hardpan'] Adobe ❑ Fill Material If es, type �Ibuildings, etc. must be placed on reverse side.) (Plot plan, showing size of;lot, location of system in relation to wells, 11 ' pitermitted if public sewer is available within 200 feet,) NEW INSTALLATION: (Nb septic tank or seepage p' p p ' � - Liquid Depthth ---------------- Size------------------ - - PACKAGE TREATMENT 11: , SEPTIC TANK'[ ] ''+ _, il atenal"--_.-----'---- No. Compartments - ----------- --• - -- \ Ca acit Type ---------- -------- Mv -- Pro Line ---•------------------ Distance -----Distante to nearest: Well -_--__-_-----"-- -- - Foundation = p' � - --- Tota! Length ----------------------------- 'Material --- ------ •---------------- t- LEACHING LINE I ] N o. of Lines -------------- -------- Length of each line--------------------- ' Depth Filter Material -------------------- ---------------------•- Di Box ------------ Type Filter Material ------ P I ------ Foundation ------------------- Property Line Distance to nearest: We -."--------- ----- Diameter De th _------------- Number ---------------- ------ Rock Filled Yes ❑ No SEEPAGE PIT [ ] ilP ------ e Rock Size ------ ----------------- � Water Table °Depth -- ---------------- ---------------•=-�-------- - i`: � I Pro Line -------------------- Distance to nearest: Well ----------------------------------------Foundation ---------------- P .� _. ---------- Date ) (Prey. Sanitation Permit -- --------------- ----------------- Septic Tank (Specify Requirements) -------------------------------------------------------------- Di sal Field (Specify) Requirements) ------------------------------•------------------------- • ----------- -'" -- 4 ' ------------------------------ --- . ------ ------- -------- -------- ------ (Draw existing and required addition on reverse side) t 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 .F. as to become subject to Workman's Compensation laws of California." Owner Signed ---- -- - --- - - `�� ------- - ------------------ - { i .- -•--- ------- ---------- Title ------- - - --- ----By t_---- (If other than owner) I� FOR DEPARTMENT USE ONLY DATE �_~-`{_-��- ---•------------------- APPLICATION --------- --APPLICATION ACCEPTED BY _. ----=-------- DATE -- --- ----------------------------------- BUILDING ------ - - -- --•- BUILDING PERMIT ISSUED ----- ------------------------------------------------------------------------------------ --- ------------------------------------ ------------- ---------------- ------------------- ADDITIONAL COMMEN S ------------------------------------------------------------ ----- -------- - __ -------- -------------- --- -- ----- ----- - �I--------------------- ------------------- ------ ---------- !N------------------------------------------------- --------------- ------------------------------------------- ---------------- ----------- ------------------- ---- Dat Final Inspection by: -- - - - - - - -- - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M