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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------- - 3 (Complete in Triplicate) Permit'No _7`� / _I--------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Applicatiori-is hereby made to the Sbn 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: j. JOB ADDRESS/LOC'ATIONPM.lVl�/�' �--,W491,/Iyfy�6 ( _../a0dA v4,WtENSUS TRACT -------------------------- Owner's Name/r` r C kt4.. -='.-✓fes � `r- �`�� Phone r Address --- _G �f �(1E� �� • City. 1/1� _l-------------------------------------•-------- Contractor's Name --------------------------------_----------License Phonex��4/h ___ Installation will serve: Residence ❑ Apartment House❑ Com ercial ❑Trailer Court ❑ Motel ❑ Other - -l -------------- Number -------__ Number of living 'Units:.__"----- Number of bedrooms .--"------- Grinder �1�___ Lot Size 4�4�� k* ------ 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 ---------------------------- 0 (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 publ sewer is available within 260 feet,} J PACKAGE TREATMENT [ ] SEPTIC TANK {J t Size-0, ___._. Liquid,Depth - ------ ----------------- Capacity/M17 ------------- , Capacity/M17___-__ TypL� T__ Material_G� �� No. Compartments _1r_......_:__.. W. Distance to nearest: Well ---________________Foundation ---------- Prop. Line s01 1 _ ....______ LEACHING LINE No. of Lines - � Length of each fine1 _:--- Total' Length .i� ---------- 'D' Box __ Type Filter Materia}- �1 ____ epth Filter Material --------------_------------___..._____ 1 Distance to nearest: Well __4�_"J�-__ Foundationt -----_ = Property Line. # -rl`�------•-"-- iY�� SEEPAGE PIT [ ] Depth _______ __________ biameter .______ ---------- Number -------------------------.__ Rock Filled Yes ❑ No :0 { Water Table Depth ---:- --- ---------------------------- -------Rock Size ----------=----- ---------------- Distance to nearest: Well ____euireitrion ___ _______Foundation ----- ---------- Prop. Line ______-_--____-______- 1� r _ rt REPAIR./ADDITION{Prev. Sanitation Permit#, --=f------ ------------- #e -------------------�--------------} Septic Tank (Specify Requirements) --------- -= ----- ------------------------ Disposal Field (Specify Requirements) ------------- N`t ----- ------------- --------------------------------------- -------------------- ------- ---------- e ---se---- - ------------- : :{Draw existing ation 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 ------------ Title --------------------------- other than owner) ` x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---C-_ - DATE .z- 1`-7j --------------------- BUILDINGPERMIT ISSUED -------------- -------------------------------------- ----------------=--------------DATE ---------------------------------------- -- ADDITIONALCOMMENTS ------------------------------------------------------------------------ -- - ------------------------------------------------ ------------------------ -- - ------------------ - --- ---------------i-,----------------------- ---------------------------------------------------------------------------'------------------------------------------- ---------------------------------------------------------------------------------- - - ------- --- ------- = ------------------------------------------------------- ------------------- ------------ - - -- - -- Fi.nal Inspection by: � ---------------------- - - --- -----------------------------------------Date ---�"/f---�-- ----- -•----------- SAN JOAQUIN LOCAL HEALTH DISTRICT s-9 E. H. 9 1-'68 Rev. SM