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FOR OFFICE USE: i ' APPLICATION FOR SANITATION PERMIT 3 - - ' �-� - - --------- - Permit No. �� '� (Complete in Triplicate) - -- -----•-•` � ` Date Issued -------------._______ -_-/`-_ This Permit Expires 1 Year From 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 CCc��ompliance with County Ordi nce No. 54-9 and existing Rules and Regulations: JOB ADDRESS/LOCATIONN---- - 7_ '-- .�Y.�[-_ ----------CENSUS TRACT --------------_---------- Owner's Name --------------�C J - !1 - Phone Address - City ` ---------------- --- ,_60 Contractor's Name -------- ---- - '----<, ---------------License # L3J // Phone Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court i❑ MotelF1 Other ----- -------------------------------------- Number of living units:_______ Number of bedrooms __3_-_Garbage Grinder ------------ Lot Size --_ 6_X_. _t------------ 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 ❑ Adobe ❑ Fill Material ___________ If yes, type ---------------------------- (Plot ________________________(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 _________________Depth Filter Material ____________________________________________ Distance to nearest: Well _____________________ Foundation Property Line -----------------__-- SEEPAGE ___________-__ ___SEEPAGE PIT [ ] Depth ______ Diameter _____________ Number -------------- ------------- Rock Filled Yes ❑ No ❑ Water Table DepthRock Size ________________________________ ------------------------------------------------ Distance to nearest: Well ________________________________________Foundation --------- ---------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __________________________________) Septic Tank (Specify Requirements) _______-____-_______________ ___ Disposal Field (Specify Requirements) ---------- -�----------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- ------- _'L Lit - -------------- - - - - 6,- Xs-------- - (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 --------4-' (If of than owner) --------------------- ---------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------ -----. DATE -----91- -17.2--------------- BUILDING PERMIT ISSUED ---X -- ---/_______ DATE _____________ ------------------------------ ADDITIONAL COMMENTS _.3 ?cF__7_ ---- -5% � a'�e'c�_ - ' ----------------------------------------------------------------------------------------•--------------------------------------------------------- ------------- ------------------ - --f- ------ ----- ------------------------------------------------------- Final Ins ection bY - - Date ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M