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FOR OFFICE USE: ------------------------- - APPLICATION FOR SANITATION PERMIT - -------=--------- (Complete in Triplicate) Permit No. ...... -- - ------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicationg0'.e in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .__-__ "q711`-__ ------ --------------------------------CENSUS TRACT Owner's Name ------- "-E'--�-'�'•�_ _ ------ -- -lam _ _ Phone --- Address ----- �s r --V-yl -c h 0 `- CitY -------- �-_O a----1-p-'�------------ ----------"----•---- Contractor's Name _ I - { ------ t !- L- GLYI-----_.License # -©--�c�---- Phone �� C1 Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court Motel ❑Other------- Number of living units:---I------ Number of bedrooms ___ ___Garba e Grinder ________ Lot Size _.__ ___ g 1y Water Supply: Public System and name _____.______________-_______ -------------------------------------- _ Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeFill 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 ( Size Liquid Depth ................... . Capacity __-DEQ_____-__ Type __ ------ ter __ Maial___ _ . _ __.___/No. Compartments Distance to nearest: Well U_ U ------------Foundation _____%Li_`.____ Prop. Line ...lG?l�__..._-. LEACHING LINE J�Q No. of Lines ___ ___-_____ Length of each line--------lovio__t_-_____ Total Length ,__, 'D' Box T ` 0o Type Filter Material ------ 0o Filter Material ________1_q Distance to nearest: Well 1C ( -'----- Foundation ___-----___--_ property Line ___ _.�......... SEEPAGE PITDe Depth �(1 p ___ Diameter ---- -- Number ______�________ Rock Filled Yes J No ----------------- --- -- i❑ Water Table Depth 9� _-__.____•___Rock Size ______________ -------- Distance to nearest: Well __ Q --------------------Foundation ____]0-_- ----- Prop. Line ------ • REPAIR/ADDITION(Prey. Sanitation Permit# _________ ---- _________ ---------------------- Date -----------; -------- -------------------------- Septic Tank (Specify Requirements) Q Disposal Field (Specify Requirements) _________l_ Q__`.___._ ' r` a' ! 7----------------------------------- -------------------------- ------------------------------------------------------------ ------ /0 - ---------------------------------- --------------------- -- ---------------------------------- (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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner $r 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 - -------��------- (if other than owner) --- FOR DPARTMENT USE ONLY APPLICATION ACCEPTED BY _____! �� __- _ _ BUILDING PERMIT ISSUED ----------------------------------------------------------- ---------------------- DATE _` --/�--- 7�------ - ADDITIONAL COMMENTS ------------------------------------------------- -•------------------------- DATE ----------------------------------------------------------------------------- ----- ----- ----- ------------------------------------------------------------- - - - ---------------------------- -- - - - ---- Final Inspection b ------------------------------------- ---- - - -- -- P Y° - D e - ------- -------------- ------------•- SAN JOAQU LOCAL HEALTH DISTRICT 1-'68 Rev. 5M_-_ k� -