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FOR OFFICE USE: N_.. APPLICATION FOR SANITATION PERMIT / _ ----------------------- -------- -- ------ ------- Permit No. -- -- (Completein.Triplicate) - Jq ' . �_ . This Permiexpires i Year from bate Issued Date Issued Application is hereby,maEl a 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: �i p------ a - CTRACT' ---'-'-.------------------ JOB ADDRESS/LOCATION ------------------ N Owner's Name -_____ -_- x o _---- -- ---------- ---------------------------------------- Address -..�f-fd �I ` CitYt --Phone -------------------------- - a , Contractor's Name *_- -f - --------------- ----- ----;.License # AS 1,P'3--- Phon'e'--V4l` � Installation will serve: Residence)R'•Apartme nt-House,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------- Number ------------------Number of living units:.-,✓�__-- Number of bedrooms .I-_--Garbage Grinder ------------ Lot Size ---------------------------`._.._.._.._ Water Supply: Public Systt m and name ------------ --------------------------------------------------------------------- 4 Private 'Character of soil to a depth of 3 feet: Sand'❑ Silto Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ a Hardpan ❑ Adobe K Fill Material __*--------- If yes,type --------------------------- (Phot plan, showing size sof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: i NA {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [y] SEPTIC TANK f ] Size----------------------------------------- --- Liquid Depth ------------------------ _ �► fi Capacit.11! y TYPe ------ ------- Material-------------------- No: Compartments -----------•-•--- Distance to nearest: Well -_----`----------------------- ----Foundation ----------------------- Prop. Line ------------.._._------ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------_-------------- --- Total Length ---------------------------- .0: 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _-------_--_--_.--_...._...__._-_-_.__-_.___ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _--_-_-_-_---__--_----_- SEEPAGE PIT [ ] Depth -______-_-------__- Diameter ---------------- Number --_----_......__._____.__. Rock Filled Yes ❑ No .0 :il I Water Table Depth ------------------------------------------------Rock Size ----------- -------------------- 1 Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -_------------------- .1 REPAIR/ADDITION{Prey. Sanitation Permit# -------------------------------------------- Date ----------:------------ = ) Septic Tank (Specify Requirements) -------------------------------------------------------•--------- - ... • Disposal Field (Specify.IIRequirements) --------------------------- _G% Lam/--____ D �. - i , - - ------- �� ---------------- ---------------------------------------------------- - -------------------_ ------------------- - ------------------ - o {Draw a stin and re aired addition on reverse side)�r 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 as to be a sub)ect o Work 6n's Compensation laws of California." Signed . . U Imo✓ -. f.7 ---- . --P__------'s-;--- - - --------- --- --- ----- Owner BY ---- ---------------------------------II = = Title ----------------- (If other thari�owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ----- ------------ --------------=------------------------------------------- ------- DATE -------- --•--------- BUILDING PERMIT ISSUED11!---'-- -------- - -------------------------------------- ----------------DATE ---------------------------------------------- ADDITIONAL COM NT [ - -------------, -� ____ _ ____ /f� �� - p Y . ---- -------- --- - - {� l --- -- - ---- - - - ---------- - Final Inspection b- ---------- --------- -��----- --------- ---------------------------- - -----:----- --------- � �,1, 22 ----------------------------------------------------- -------- ------------------ -- ------------------Date --- ---------------------- i 77 SAN JOAQUIN LOCAL HEALTH DISTRICT ` E. H. 9 l-'66 Rev. 5M E141