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r � FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT ' -C��-- . Permit No. - ------- ------ --------------------------------------------- ----------- jComplete in Triplicate) ---- ---I-------------------- -------- --------------- Date Issued N This Permit Expires 1 Year From bate 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 CountyjOrdinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION Gf-- CENSUS TRACT --------------w----------- Owner's Nane - UES = ------ ------------------- --- ----- Phone f :i ' Address -------- /l� -� . -FFE rJCH 1-RI) City } -------------------------- F_ f , t° a Contractor's Name _._0171 _�:�------------------------1 -------------------I= License # ---------- Phone ----------------------------- i ' II Installation will serve: Residence ❑Apartment House 1n, Commercial::❑Trailer Court '❑ r Motel ❑ Other -- ---------- ------------------ ---- {< `' ;� Lor Size ACR�_5 o. Number of living units:-._ �.__-__ Number of bedrooms_----- r - Y �' Private Garbage Grin �� Water Supply: Public System and name ______--______1- tai----------------#----- i - 3 Character of soil to a depth of 3 feet: Sand'❑ Silt�] Clay ❑ Peat❑ Sandy Loam ®---Clay Loam ❑ I: __ Hardpan E-] i.Adobe'❑ FiII Material __._ L--if If yes,type -------_------------_-------- (Plot plan, showing size of lot, location of system in relation,to wells, buildings, etc. must be placed on reverse side.] S +� j: NEW INSTALLATION: (No septic tank or seepag]e_pit_permitt�d .if pu$I:ic sewer is available within 240 feet,) Y �` ._ � _=---- PACKAGE TREATMENT [ ] SEPTIC TANK!F.� Size'�X:�.�-. -=�--~--- ----- Liquid Depth Ca aci � �� ---- Type 5915'51 Material----- =�V_ - No. Compartments ------•---- --•----•- P tY ------ - Yp ,, , ��- .�© _I_`' -------------Foundation ------�----t-- Prop. Line ------------- Distance `�� to nearest: Well ______________ _ _- LEACHING LINE [G]�No. of Lines ------------- Length of each .line-____+ �--��:----- Total Length ____..� - <--_--- Y -- / �q �r 'D' Box/ -S- Type Filter Material 4_ K__Depth Filter AAaterial ----------- ----------• �� — "_ " Property Line. --5---- 5' Distance to nearest: VVeII_-----:- ------=�=�=-- Foun�ation _. ----------- SEEPAGE PIT'. [ ] Depth ____________________ Diameter ----------------- Number -----------`--- Et----- Rock Filled yes :Cl No C3 Water Table Depth - ------------ -- ='-----,Rock Sizer '' I 1'J y c . ;-� � �c t . Distance to nearest: Well ------------- -- .`-•--,----=,_, !__Foundation .------ -------- Prop. Line ----___..--------- REPAIR/ADDITION(Prev. Sanitation Permit# `---------------------- - ----------------- Date ;------.------ -\----- -----1 t\ 4x Septic Tank {Specify�Requirements) ------------`------ -------------------------------•- ll--------------.._-,- - ,� .. Disposal Field (Specify Requirements) -- -- ------- 1 - {f ------------------�. -------------------------------------------------------------------------------- ---------------- S -------------------=----- ------------------- --------------------- ----_------------------------------------\ - ------- --------------- R ---- __-- �----------w- � - (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 .loaquin 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." ISigned - ------------------------------- -------•----=-------- Owner ' 'G� ------- Title --------------------------- ---------------- --------------------------- BY -- - --------------------- (If er than owner) FOR DEPARTMENT USE ONLY ! DATE :- APPLICATION ACCEPTED BY ---------T-113,_0----- ------- ------------------------------------------ 3---- BUILDINGPERMIT ISSUED ------ -------------------------------- ---=--------------------------- ------------- --DATE ---------- -------------------------------- ADDITIONAI COMMENTS . ------------ - - ---------- ------------- - -- ---------------- is _ - - _------ ---- ..— ---------------- ---- ----- ------------- ------------- ----- --- Date ----- Final lnspectio p SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.