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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------"-""" (Complete in Triplicate) - ------- -------------------- Date Issued _-- '-- -"7 ----------- ------------------------ --------------- chis Permit Expires 1 Year Prom ate issued truct and e work Application is hereby made to the San Joaquin l Health District Ordinance e permit to cons and exist ing Rules tand hRegulafio stein described. This application is made in compliance JOB ADDRESS/LO A70N zr � _---- --- ------------------ ----------- - CEN-`SUS .TRACT3 -,-,-,, -,- ------ -------------- 'a -•------------- -- .a1Phone 1 --- --------------------------------------------------- owner's Name __ ?� �� Cifi 79C- ----- ---------- -------- - ---- --- -• Address N License /c 'l Phone ------------------------ Contractor's Name .--- t---------•- ` Residence Apartment House❑ Commercial :❑Trailer Court 1E]� Installation will serve: Motel ❑Other ------------------------------------------ __ _ Number of bedrooms ____��_ ""-_--Garbage Grinder --_--------- Lot Size - _---� ----------- Number of living units:__._ - I Private 0 Water Supply: Public System an name ------------------------------- ---- Cla Loam [3Character of soil to a depth of 3 feet: Sand'® Silt❑ Clay El Peat F1 Sandy Loam ❑ Y Hardpan ❑ Adobe ❑ Fill Material ------ If Yes, type ---------------------------- se side.) F Ian showing size of lot, location of system in relation to wells, buildings, etc. must be placed on rever } (Plot p , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Liquid Depth - ---------•--•--•---.----- PACKAGE TREATMENT I ] SEPTIC TANK![ ] Size---------------------------- -------- - - q ----- Material-------------------- No. Compartments -------------- ------- CapacrtY -------------------- Type _ Pro Line ----------•--=•--•--•- Foundation ------- p Distance` to nearest: Well ____---- -------------------------- -------- -- - t Total Length ----------------- ---------- ------------- 'D' - -- -- - - - - - - Le th of each line----------------- '--- -- LEACHING LINE j ] No. of Lines - j -Depth Filt r Material -------------------------- ------------•---- D' Box _-_--.---- Type Filter Ma tial "----------• p Property Line ---------------•-••--•-- ` Distance to nearest:'Well ------- ------ Foundation ------- ----- p r SEEPAGE L ] Depth ------------------ a meter _ Number -------- - ----------------- Rock Filled Yes ❑ No i Water Table Depth __ ` --------Rock Si e ------------- ------------------ t --Found tion -------------------- Prop. Line -----------•------- -- Distance to nearest: Well - -- -------------------------- ! Date -------------1 REPAIR/ADDITION(Prev. Sanitation Permit :------ --- -- f Y I Septic Tank (Specify Requirements) f------- _, ( Disposal Field (Specify Requirements)_----- M ----------------------------------------------------------------------------------------------------------•--- ------------- _ 4 _ e ---------- ------- r =- --------------------------------- ---- --------------------------------- -"" -----------------------------------------(Draw exisfiing and required addition an 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 certifies the following: erson In suds manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any p as to become subject to Workm 's Compensation laws of California." - Owner Signed Title ---- ----- --------------------- BY ------- ------- (if other than owner) FOR DEPARTMENT USE ONLY �� / DATE --- ------ ----- �-------------- DATE ------ ----• APPLICATION ACCEPTED BY DATE ------------- ----------------------------- BUILDINGPERMIT ISSUED ----------------------------------------------------------------------- ----------------- -- --------- ADDITIONAL COMMENTS ------ ---------------------- ------------------------------------- - --------------------------------- -------------------------------------------- ---- -------------------- _ .: ------- ----------------- _ ---- ------ ------- ---------------- -------------------------------------------------------------- - - - -- ------------------- Date , Final Inspection by: ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT F H- 9 1-'6$ Rev. 5M _