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FOR OFFICE USE: V "- ",- - ^,/ r" 5'' APPLICATION FOR SANITATION PERMIT '- -- �� (Complete in Triplicate) Permit No. '` _. J Date Issued _� ,/? ----------------- Date-_ - _____________ 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 compliance with County ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION _ ---_ 1 /- - -, - ' _ _-_ _CEN SUS TRACT __ Owner's Name ___r ,177 - -------------------- ------------1- --P one -------------------- Address ---------------- ' - -- - f - ---- - City -J-4-'e, ---------------------- -------------- Contractor's Name _________ ea --------=------- --License � Phone Installation will serve: ResidencePpartment Hous:e,❑ Commercial ❑Trailer Court Motel ❑Other ---- Number of living ur4ts:_,-/----- Number of bedrooms ., ----- ar�aage Grinder _lke Lot Size Water Supply:<Publi�yste�ggd name _ _ �_ -------�s- 11 - - " .� -x C ------------------------------Private ❑ Character of soil too a,d.Pbth of 3161: Sand'❑ Silt❑ Cla ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan E] Adobe pterial ------------ If yes,type ----------._-__---__ (Plot plan, showing,size of lot, location of system in relation t wells, buildings, etc. must be placed on-reverse side.) NEW INSTALLATION:, ..(No septic tank or seepage pit permitted Lf public sewer is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK[ ] Size---i /---------------------------------- ---- Liquid Depth ---------------------- \ i 4 Capacity ------------------- Type -------------------- Material---------------------- No. Compartments t Dista'E1e,to nearest: Well ---------------- _Foundation ____________ _ _____ Prop. Line ---------------------- L ACHING LINE "Lm" es [ ] No71— 1.1 of ------------------------ Length of each line---------------------------- Total Length ----------- ................ i 'D' Bpx ____ Type Filter Material _______-_-_____---Depth Filter Material ---_______--____ f' --------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE --___--_____-__.__ -SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth ------------------------------------------------Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITIbN(Prev. Sanitation Permit# -------------------------------------------- Date Septic Tank(Specify Requirements) _____________-______ ___ Disposal Field (Specify Requirements) ------- ----------% r o rj --------, -------------- ------------------------------------------------------------------------------------------------------------ ----- ----------- ----------------------------- --------------------------- - --.--- - -- - - - - - - -------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I'herebV certify that 1 have prepared hhis application and that the work will be done in accordance with San Joaquin �unty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- s agents siinature certifies the following: "I certify that ih the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subfeut to Workman's Compensation laws of California." Signed ----------------------- Owner By ---------------------------- --- ' - _-- -- ---------- -----------------• Title �-- --�2=/��=�'_..--- ---------- ------- (If t an owner) -- `' FQR DEPARTMENT USE ONLY APPLICATION ACCEPTEDBY ______ __ _ _____ " BUILDING PERMIT ISSUED ADDITIONAL COMMENTS --- ___________ - DATE �f � � --------------------------------- -- -- ----------------------------------- DATE ----------------- - - -- -- -- -- ------------ - -------------------------------------- --------.---------------------------------• --------- ------------- ---------- --------- --- ---------------------------- --- ------- - --------- ---------------------------- --------------------------- - ------•------- -------- - -- - - --------------------- Final - --------- ------ Final Inspection b - / ___ _ __ ________________ p Y -- ----------- -- ------ -----Date _lc�a_�_/_-,--- ------ ------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M