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FOR OFFICE USE:- APPLICATION FOR SANITATION PERMIT ----------- --------- --------------- ------------I�---- II (Complete in Triplicate) Permit No: ___ ---------------- /,5-- ---------_:._ a Date Issued -�`�5=.7 .. __________________________ fl _ __ __ ___________ 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. �4 r? S'- 3 P_uw^„J '�-J"n.� r46�1: 25-7–roto–o y . JOB ADDRESS/LOCATION' j �+ - _.........om-N- -- 0?�64gn/_._�- ---------------CENSUS TRACT ------ -------- 7�Owner's Name -----/T2q_k)&------iNvf- ------------------------------------------- -------------------------------------Phone _67 -� ------b--- Address S 1CityG - �- 1 Yf Contractor's Name =- _ _C� _ -----------------------------------------License # 1Phone Installation will serve: Residence ®Apartment House,❑ Commercial ❑Trailer Court ,❑ [ Motel ❑ Other ------------ Number of living units:_.__I_/--_ Number of bedrooms -3------- Grinder ------------ Lot Size -_! !_ -________________ 1 Water Supply: Public System and name -------------------------------------------------------------------------------------- -----------------------Private Character of soil to a depth of 3 feet: So ^" depth ❑ Silt❑ Clay- 0 w Peat❑ Sandy Loam Clay Loam:❑ I Hardpan ❑ Adobe.0 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: (Nio septic tank or seepage pit permitted if public sewer is available within 200 feet,) t i PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------------- _- ----------- Liquid g - ` epth --- ------- ------------- ` Capacity- ------------------ Type ------------------- Mater' I------------- -------- No. Compartments --------- ............ Distance to nearest: Well --------------------------- --------Foun tion ---------------------- Prop. Line ---------- LEACHING LINE [ ] No. O of Lines ____ __________________ Length of ch line__. ----------------------- Total Length _._________,. __-_-_ 'D' Box --------- Type Filter Material _______ _________ epth Filter Material ____---_-_________________....____.___-._� �--- Distance to nearest: Well -------------- --------- Foun ation ------------------------ Property Line ------------------------ I SEEPAGE PIT [ ] Depth ____________________ Diameter --------------- N mber ---------- --------------__ Rock Filled Yes ❑ No ❑ Water Table Depth ------------- --------------------- -----------Rock Size -------------------------------- Dis`ance to nearest: Well Prop. Line ______________________ --------------------- ----- ---------Foundation --------------------- REPAIR/ADDITION(Prey. Sanitation Permit# ------ --------------------- ----- -------- Date ---------------------.-----------_ Se tic Tank (Specify Requirements) ----------------------------------- --------------------------------------------------------------}- ---------- Disposal Feld (Specify Requirements) ---------------- -------- ----------------- ------------------------------------ -------- ---------- y---------------------- ---- :, -. -- --- ----- --- - ------------- -- ---- ^------------------------------------------------------- ---------- (Draw 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 certifie"s the following: "I certifythat 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 -- --------------- - (If other than own *� FOR DEPARTMENT USE ONLY -� APPLICATION ACCEPTED B� 'T-4-9--v BUILDING PERMIT ISSUED iY DATE -_-_ -._- �,�- - ------------- -- --- ----------------------------------------------------- ------------------- -------DATE --------- . ADDITIONAL COMMENTS 'I -- -------------------- ---------------------------------------------------------------------- ------------- ----------------------- - --------- --- -------------------- -- --- ------- -- --- - ----------------------------------------------------------------------- ,r --------------- ---- -- ------------------------ ----. -- -- ----- ------------ ------- - - -- ---- -- -------------------------------------------- Final Inspects • -------- - -------- -- ------- _ Date --------------------� A ---- --------- SAN JOAQUIN .LO�AL�HEALTH DISTRICT - 4 t E. H. 9 i-'68 Rev. 5M I