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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: ---72-��4-----b ----------------------------- _------ -----_-------_-------_--------------- This Permit Expires,] Year From Date Issued Date Issued �0__.W_7y 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 County Ord.ii nce—No.;.549 and existing Rules and Regulations: JOB ADDRESS/LOCATION.______ _-_____�, _a-+- -G+- -__--------- + ' =CENSUS TRACT - Owner's Namea �r'3�►'2.0 S(' - Phone Address ---- = -/a -F' - -5 - Cit i Contractor's Name ---_ _-- 5 —_-_�_-,------- -----License # JFI-Sf.�'----- Phone ------------•_-_--_--•------- I Installation will serve: Residence [ Apartment House-E] Commercial :❑Trailer Court ,❑ Motel ❑Other ------------------------ ------------------- Number of living units:----- _- Number of bedrooms ____7�__Garbage Grinder ------------ Lot Size ________-________-_______________________ l� Water Supply: Public System and name -------------------------------------------------------------------------------------- •--- ------Private ❑ O 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 be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f Size________________________________________________ Liquid Depth -_-__--____-_________,____- Capacity --------------------- Type ----------------- -- Material---------------------- No. Compartments ------ .......... Distance to nearest: Well ----------------------------.-......Foundation ....._..____________.. Prop. Line ...................... LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length -----------._._______._.____ t 'D' Box ..__-__ .... Type Filter Material __________________Depth Filter Material --------------------________________________ Distance to nearest: Well _____________________ Foundation ------------------------ Property Line _-______________-_-___ SEEPAGE PIT [ ] Depth ____________________ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ -No 1❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Di stance ------------------------••-- •-Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date -----------------------------__j Septic Tank (Specify Requirements) ----------------------------------------�-------------`-�--------g-------------•--- ----- •--•--••--- Disposal Field (Specify Requirements) ---4-%4�...._-____ ______________ ��^ -- ----- ---------------- ---------------------- -------------------------------------------------------- - ----------------------------------- ---------------------------------------------- (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 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 become subject to'Workman's Compensation laws of California." Signed -------- ---------------------------- wre!� ------------------- Owner A BY Title _ -•�- -- ----------------------------------- ----- f (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY a ---------------------------------- -- -------------------------- DATE S ------, .... L-•-------- BUILDING PERMIT ISSUED --- ------------------------------------------------------------------------------------------------------DATE ----- ---------------------------•-----___- ADDITIONALCOMMENTS ------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- -------- ----------- - ------- ----=- - ------------------------------------------- --------------------------- ---- - Final Inspection 6y: -- ------------ ------------------------------------------Date- -- red-�� '+ -7- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M