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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT N ---------------------%.a Permit No. Z- Z.O J, , (Complete in Triplicate) I Date issued _._�T -------------- 0 . ___.__--____-___-_L�_ _._._.___AC1 � ______ This Permit Expires 1 Year From Date Issued h� 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .pli--ff---45-0_-o1lr�'474----------------------- ----------------------CENSUS TRACT Owner's Name -__V,77 ,(� � ---------------------------------------------- -------Phone ------------------------------------ Address -----k--*,Oopre — ------------- •-----------------------------. City �/1� &�---------------------------------------------� Contractor's Name ___- --_: � �---------------------------License #s /c, Phone 'r,� �!_" '•�+r� Installation will serve: Residence XApartment House❑ Commercial [-]Trailer Court ;❑ Motel ❑Other ------------------------------------------- _ Number of living units:--- Number of bedrooms _1------Garbage Grinder/ e--- Lot Size f�� ..'___. Water Supply: Public System and name ---&,,//f_,/ --- % f"___ -----------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ Hardpan ❑ Adobe 4 Fill Material ------------ If yes,type ----_____--__-______-_____ (Pl'ot 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 [ ] Size------------------------------------------------ Liquid Depth ______-_-__-------..._. NO Capacity _ _ Type ____________________ Material---------------------- No. Compartments ...................... Distance to nearest: Well _-_--_____________________________Foundation ---------------------- Prop. Line __---------------_.... k. LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------- .................. 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _________________________,---..---- ..._..-- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ___-______-____- ----------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) --------------- ------------------------------ -11--- -- --------------------- --..��..... Disposal Feld (Specify Requirements) - � � ---------------- 0��-...... ,� , `�--- -- __/0_1................ ----------- f' _5. - -- ------------------------------------------------------------------------------------ (Draw existing- and required aefdition`on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- --- Owner BY --------------------- Title ------------------------------------- -- her than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ----------------. DATE _-- -- �-- �------------------ BUILDING PERMIT ISSUED --------------------------------------------------- ---- ----------------------------DATE ------------- ---------------------------- ADDITIONAL COMMENTS ---------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------- --------------------------------------------- ---------- ---- ---- - ---------------------------------------------------- ------------ ------- --------------------- --------------------------------- ------- Final Inspection b Y� ------- ---- -- - Y�; ' � _ --- S ------ -- -'---- ----------- ------------- � _.---------------------------------------Date --- SAJN LOCALHEALTH DISTRICT E. H. 9 1-'68 Rev. 5M