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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------- - Permit No. (Complete in Triplicate) _ t ________ 1 , 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: -----------`---�--C - 'JOB ADDRESS/LOCATIOK(% _ - . ---- -- -----om--`=�-?V---a---- ---------- - �" CENS US TRACT; -------------------------- Phone ------�----/--�-•------- ----- Phoned /93..._ Owner's Name � ' ... � 3 s � -- - City Address � / -- Contractor's Name --- . .--- --------------------License # ------ PhoneC -•--•----- Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court ;Q Motel ❑Other ------ ------------------ Number of living units:------------ Number of bedrooms ___________Garbage Grinder _____:_____ Lot Size,�00o --ydd Water Supply: Public System and name --------------------------- ----------------------------------------------••- ---------------------------------Private Character of soil to a depth of 3 feet: Sand'Q Silt❑ Clay ❑ Peat❑ Sandy Loamo Clay Loam ❑ Hardpan ❑ Adobe Q 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'[ ] Size-�__-.-�----�'�-.'-`�------------------- Liquid Depth ._.' ___....____.____ Capacity- ------ Type _211(4,71--- Material_��J?_--'------ No. Compartments --a.............. (� Distance to nearest: Well /_G_d__ __----------------------Foundation ___ O_______.. Prop. Line .4-7.4� ____.____- LEACHING LINE No. of Lines ___ _______________ Length of each ---/�n-_-___.._____ Total Length ,____ 4Q_�_______.__ 'D' Box Type Filter Material� _�_4__bepth Filter-Material _____`8_______________________________ �l Distance to nearest: Well '`_______ Foundation _. d_ ____________ Property Line _.__....... SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number _______.___ --------------- Rock Filled Yes 'Q No 0 WaterTable Depth ------------------------------------- ----------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation _--____---____._--- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------•--------------------••------------------- ------------ -------------- -----------_- . DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) I hereby certify that 1 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 be me subject to Workman's Compensation laws of California." Signed x `� - r- ------------------------- Owner -� ------------------------------- ----------------------- By ------------------- -------------t ---- c-_c -- - Title (If other than owner) 7 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY `• '-'""`------------------------------------------------------------ DATE _3__� `�' BUILDING PERMIT ISSUED _ DATE ___________________________________________ ADDITIONAL COMMENTS 1 o� L�' inl--r1'7T«� G�,`i�i"�f' --------------------------------------------------- ------------------------------------------------------------------- --------------------------------------------------------------------------------- ------------ --------------------------- ------ Final Ins ection b ----------------- -------------Date -- --J------- ----------------- P y- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M