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FOR OFFICE USE: ------ --------------------- APPLICATION FOR SANITATION PERMIT Permit No. --------- -----�- (Complete in Triplicate) ____________--------------- This Permit Expires 1 Year From Date Issued Date Issued -_ 4__-_�y 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: 6 JOB ADDRESS/LOCATION . _d-_-c� I' -f,�� !['► --------------[_►1T -----------.------CENSUS TRACT ------ .............. Owner's Name -----J-rag_g__r— _zt------- y��;� ----------------------------M---- -------Phone ------------------------------------ Address -----1---f c3 Z _ �1 11I/ ---------------- City - /'1 Irl �' ------------------------------------------ FV - n/ -fir Contractor's Name _____ __/L____._._ �'C_� �"r1_�4 __._______.:.______.License # �T�� Phone _LZ_� --.�..... 1 Installation will serve: Residence Ap rtment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------r-�------------------------------------ Number of living units:----1------ Number of bedrooms .__ -------------------------------- Water / !i c___Garbage Grinder Lot Size ___J3;_000--[1--_" ----_--__-- Water Supply: Public System and name ---------------------- ----------------------------------------------------------------------------- ----------Private' Character of soil to a depth of 3 feet: Sand, Silt❑ Gay ❑ 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 [ ] Size-----------------------------------.____.------- Liquid Depth -------------------------- (� Capacity -----------------.-- Type -------------------- Material--------- -------- No. Compartments ----------•----•---•-- W Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -._-________-____-_.•.- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ........... .............. 1 '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) ----- --- -------------- 4------ p` ------ ------• /� , ------�xaAe-411,1 Disposal Field (Specify --_--_-__-__Requirements) ------------------------------------------------------------------------------------------------------------------------- --------------------4-_�---J�----X----2y_1� -------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- 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 become su bjlect to W man's Com en tion laws of California." Signed �'-'�1 Owner BY --------------------------------------------------------------------•------ ----------------- Title ---------------------------------------------- ------------------------ (If other than owner) 1� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -=---------------------- ----------------------------- --- ---------------- DATE ------- --- 1s -67�------------ BUILDING PERMIT ISSUED -- ---- ----------------------------------------------------- ---- --- --------------------- DATE ADDITIONALCOMMENTS - - ------ ------------------------ -------------------------------- ------------------------------- ------------------------------------- ----------- ----------------------------------- ------- -- -------------------- ------ ----- ---------------------- ---------------------------------------------------------------------------------------- ------------------------------------ --- --- - --- -- -- - -- --- -- ---- - ------ ------------------------------------------------------ ------ --=------- Final Ins n by: --------------------------------------------------Date ----- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M