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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT 1 -10 �- _ -----------------!-�--------------- 7,:v- e", #Z (Complete' in Triplicate) Permit No: --------------.-� 1�� Date Issued e—lf,70 - ---------------------------------------------- ------- This Permit Expires 1 Year From Date Issued Application is'hereby mae to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is ad -ompliance with Count di a ce:�4o. 549. and gxisting Rules and Regulations: m y JOB -ADDRESS/LOCATION,' �&" 0,1V- 4Z?D�5� ---------------------CENSUS TRACT -------------- ----------- Owner's Name --------&Z/2�ftlw-------------------------------------------------I-------------------Phone ------------------------------------ Address ------ ------------------------------------------------------------------------- city ------------ ............... ------- ir Contractor% Name ---- -- ----- - 'e" eF-----.-.License # Phone ..... .Z:! ----------- ---- Installation will serve. Residence_�Apartment House,E] Commercial:E]Traile:r Court E] Motel ❑ Other -------------------------------------------- Number of living units:---/------ Number of bedrooms __,�2-----Garbage Grincler,,'I-��4P-__ Lot Size __C; --------------- Water Supply: Public System and name ---------------------- ---------------------------------_- ------------------------------------------------Private F1 Character of soil to a depth of 3 feet: Sand[] Silt 0 Clay E] Peat F] Sandy Loam ❑ Clay-Loam ED Hardpan ❑ Adobe'E] 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,) PACKAGE TREATMENT [1] SEPTIC TANK I Size------------------------------------------------ Liquid Depth -.------------_---__-,_._. Capacity --------- ---------- Type -------------------- Material---------------------- No. Compartments ----------------- Distance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line .............. LEACHING LINE of Lines ------------------------ Length of each line---------------------------- Total Length ---------------------------- 'D' Box ------------- Type Filter Material --------------------Depth Filter Material ----------..--.----.__-_--........._...:_--• Well --- -------------------- Foundation Distance to nearest. ------------------------ Property Line ------------------_--- SEEPAGE PIT Depth --------- ---------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- D[ stance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --- --------------_- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------.-----.--------------•-•_-) Septic ------- ---------- SepticTank (Specify R�Muirements) -------- ----------------------------------------------------------------------------------------------------------------------------------- 01 /11 Disposal Field ------- ...00 (Specif Requirements) :;:.. ........ ------------------------4el_42_�--- 611--t--- -- ------------------------------------------- ------------------------ -------•- --------------------------------------- ---------------------------------------------------------------- ----------------------------- ----------------------------------- - ------------- fDraw 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 Son Joaquin :1 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 perF*'0 6 rmance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to r can's compensation laws of California." Signed ---- ----------- - - -- ----------- ---- --------------------------------- Owner By ------- ---------- ------------------ ------------------- --------------------•------------------------ Title --- ---- --------- ------------ ----------- ---------------------------- (if other than owner) FOR DEPARTMENT USE ONLY , .......... APPLICATION ACCEPTEDil-BY -1-7_ej------ ------------. DATE ------- BUILDING PERMIT ISSUED ----------------------------W_( ! - --------------------- ----------------------------------------------------------DATE ------------------------------------------ ADDITIONALCOMMENTS'------ ------------------- --------------------------------------------------------I---- ----------------------------------------------------------------------- -----------------------------------------=1M---------------------------------------------------------------------------------------------------------------------------------------------------1---------- - ---------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- -------- ------- -- ----------- ----- ---------------- - ------- ------------------------ -- ------- Final Inspection ------ - ----------------- ----------------------------Date ------ -------- tion by: �?_� - - __ _`c SAN JZOAQUIN OCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M,