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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------- - -- - - ------------------------------------ This Permit Expires 1 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 Cou ty Ordinance No. 549 and existingRules and Regulations: j p TSH "I �3Rmi* ck�j �o Wy RIS �g JOB ADDRESS/LOCATION /- -«----` -- -----ON� t3----- 1 ------- ------------CENSUS TRACT .- D-......_...._ Owner's�NameM.....1\e-----_��1�eC"�hICCAv�e� ------------------Phone --•-•- Address -+h��.` �------------------------------------------• cit -. Contractor's Name m``` � 2.1 -- ---------------------------------------------------------------License --- Phone �6 Installation will serve: Residence)<Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:---- ------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---------------------- ---------------------- Water Supply: Public System and name -- AClr►i�+ 0 -_ 41O -- ---- - - Private E--- ---------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ( Fill Material ------------ If yes, type --__--_-.--_-------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must:rbe placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1, _4 PACKAGE TREATMENT SEPTIC TANK' Size----------------------- [ 7 [ � ------------------------------ ---•k -- -/I'Liqu3d .Depth -------------------------- o Capacity -------------------- Type -------------------- Material--.----------------- No. Compartments 4, ' Distance' to nearest:L-Well. ------------------------------------Foundation ------ Prop. Line -------------_-------- LEACHING LINE [ ] No. of Lines ---------Z_---- ------ Length of each line---------------------------- Total Length ------------_1....... .-_.. 'D' Box ---------_- Type Filter Material -_--__-__--__----_Depth Filter Material -------------------------------------------- ��...�,,.Di.stance_to_nearest:Well-----__-_-__._--._--_Foundation.,,_--.__-__-----.------------- Property Line ------------------------ ------------------ - SEEPAGE PIT [ x Depth Diameter ---------------- Number _.___.___._._-. '------ Rock Filled Yes ❑ No Water Table Depth ------ --------------------------------Rock Size ------ ' ' Distance to,nearest. Well --------------------------- _-,_-_-Foundation ---------------.... Prop. Line ...................... REPAIR ADDITION(Prev.`Sanitatiori-Permit-# ..--" ---_--T___"_"__'_--"Date------------------- ----------------- ---___--_-_--._- Ptic Tank (Specify Requirements) " --------------------------------------------- ) -1 -t Disposal Field (Specify Requirements- _-*1__ -J----L"l,VIIgxl rD ♦g �i s ----------------------------- ----------------------------1. ~---------.----- ----------------------------------------------------- ------------------------ ------------------------------- --` 4 # (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and-thcs! 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: "1 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 ----------- --------- ------------------ i=''---- --------- Owner BY --st---�Y. �-- --0 ------— ---- - --- ------ Title -------------------------------------------- ---------------------------- (If other than owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------------------------------------------- DATE --- r ------------------ BUILDING PERMIT ISSUED--- ----------------------------- --------.--------------DATE ADDITIONAL COMMENTS - --------------------- ---------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- --------------------------------------------- --------------------------------------------------------------------------------------------------------------------- -------------------------------------- --------- ----------------------- _ _ ---- -------------------------------------------------------------------------------------------------------------- ----- -- -- -- Final Inspection by: ------------------------------- ---•---------------------------------------------------Date ------- -+-j�.-•_-•--_ -__-_----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M C �