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FOR OFFICE USE: n� APPLICATION FOR SANITATION PERMIT ' � = - 3 0 ��//yyJJ , ' (Complete in Triplicate) Permit No. 2 a -6 �' This Permit Expires 1 Year From Date Issued Date Issued S`-fes►----------- 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/LOCA n� - _- ----�__.________ �_/_?_. �.^�------------ -CENSUS TRACT Owner's Name ------- 1 o_h-n1--------- (( ----------------=- -----------------Phone ------------------------------------ ---�--Y'-c-�--�--�,-!---��------------------- Address ------------------------------ Q - -- _ __ ------------------------- --. City ---Ei- 1------------------------------ ---------- _______________________ __ License # -,C/ _ �� Phone Contractor's Name __ R_-C�_�------- ?_ Installation will serve: Residence partment House❑ Commercial QTrailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:____ ------ Number Lof1dr o b ag Grinder ._ Lot Size .__ .____ P Water Supply: Public System and name _ 1__ __._ __- -------- -------------------------------•----Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay t❑ Sandy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe ill Material _^J4D__ 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:[ ] 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 -------------- _-.___-__-. 'D' Box --- -------- Type Filter Material -------------0____Depth Filter Material ____________________________________________ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------- ............ SEEPAGE PIT [ ) Depth ____________________ Diameter ---------------- Number -------------------------- Rock Filled Yes ❑ No iQ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well __________________________________ ____Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-.._-_-___----------------) Septic Tank (Specify Requirements) ------------------ ----- --------- ---- -- Disposal-Field (Specify Requirements) ---------- - --- --r '" ---------_ /y/ i 1/--�-- ---------- x.ST _�.l ----- =-'----------- --- Q ,� ' -------- - - - ---- - - ------ (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 -------------- ------------- Owner BY ------- ---- Title ----- ------------------------------------------------------- ( fother than owner) FOR PARTMENT USE ONLY APPLICATION ACCEPTED BY -- - - DATE - Z `F� BUILDING PERMIT ISSUED ----------- ------ = DATE ------------- ----------------- ADDITIONAL COMMENTS �ZZ- 1� -- ----- - - �' �' --- - --------------- ------------------------------------------ z 3-�� JJ�1'`�u�%y `�, --a' `w��y� 'w-"d-°�'` �----- V --------------------- -------------------------------------------------------------------------------------------- -------------------------------------------------------------------- -------------------------------------- - S - ------------------- - ----- --- ----------------------------------- ------ Final Inspection by - � - - Date ----------------- OAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M