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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT Per mit No: ------------ ------------------------------------- -------------- (Complete in Triplicate) ----------I----------------------------- fl Date Issued __________ _________ This Permit Expires 1 Year From DnteJssuecl Application is hereby me to the San Joaquin Local He istri"pct for a permit to constru.c# and install the work herein f described. This application is made' compliant County Ordinance 5e and fisting Rules and Regulations: JOB ADDRESS/LOCATIO V '`� �"�- ----- - `.__CENSUS TRACT __________________________ - - -- — t Owner's Name 'k -'` -------------- Phone f ---------- -- //' --- -- - Address _ _ / - - ----� City - '' ------.License # ---- ------------------ Phone _------- y Contractor's Name ---------�-- ------------ ----- --------------�- Installation will serve: Residence - Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑O'ther' - ------------------------ Number of living units:____(__ - Number of,bedroo ,s -.0-.---Garbage Grinder ______ Lot Size ---------- ----- --e'---------------- Water Supply: Public System a�pd name 1; ---- --------Private [! Character of soil to a depth of 9.feet Sand'g S ❑ Clay ❑ Peat❑ Sandy Loam ❑ -Clay Loam.❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type _--_-------.-_-_---__.--__ (Plot plan, showing size of at, location of system in relation t''kwells; buildings, etc. must be placed on reverse side.) NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT/[ ] SEPIC TANK [ ] Size---------- _-`-'`� = -.------------ Liquid Depth ------------I-------------- Ca acit Type -------------------- Material_._„�--___,_------_ No. Compartments _ -. ---_ -.--....__--.- Distance t nearest: Well ,n- _..Foundation __ ---____--- Prop. Line _ LEACHING;LINE [ ] No. of Line ------------------------'Length of each line------------------ ___ _ Total Length -----_ ---...----.-. 'D' Box ---._A---- Type Filter, Material ------------------_..Depth Filter Material -------------------------------------------- Distance to Aarest: Well-------------------------- Foundation ------------------------ Property Line, -_-----------------_.--- SEEPAGE PIT [ ] Depth ____________ ______ Diameter __--_-------_. Number -___-_--_____-____----___- Rock Filled Yes '❑ No .0 4:. Water Table�D ,pth ---------------------------- Rock Size Distance to near st: Well ----------------------------------------Foundation --------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permi # -----------------------------------------=-- Date ---------------------------------- SepticTank(Specify Requirements) ------------------ ---------------------------------------------------------------------------------•---------- -------------------------_ DisposalField (Specify Requirements) ---- -------------------------------------------------------------------------------------------------------------------------------- i ---------- --- -------------- ---- -------------- ----- -- -- -- - ------------ ------ - --- ------- _ - - - ----- -- - - ._ ___ a ----• ----- (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: t "I certify that in p rf rmance of a work for which this permit is issued, I shall not employ any person in such manner as to becomes or man's mpensation laws of California.” ---------------------------- Signed,.--.-..- ------ Vit'%�`Z�9 l Owner BY ------------------------------- --------------- -- --- -------------- ---- --- Title - (If other than owner) / FOR DEP ARTIit1ENT USE ONLY . APPLICATIONACCEPTED BY ---------------------------------------------------- -------- ------------------------------- -. DATE ---------------- -------------------- ----. BUILDING PERMIT ISSUED ----------------- ------- ----------------------------DATE ---------------------------------------- ADDITIONAL COMMENTS -------------- ------------------------------------------------------ -------------------- ---------------------------------------------------------------------- -11�------- ------------------------------------------------------------------------------------------------- -------- Y_--_____-____------_-___---____------__-----_____---___----____--.-_------------__-----.__-- _---------------------------_----------------------------------------------------------------------------------------.---____----__-__---____-----___----------------------------------------------------- FinalInspection by: -------- ------------------------------------------------------------------ ------------------- ------------------,Date -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTR#CT - € E. H. 9 1-'68,Rey, 5M.