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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------- - t =y ____ " (Complete in Triplicate) Permit No: . .......... = ------ --- ------ - ------------ ----------------- This Permit Expires 1 Year From Date Issued 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,.----7--------- -- j��' L CENSUS TR Tom` p1 l Owner's Name ------ , + � 0 f - Phone �C .` �(J P°• Address _. -� f CitYt 'fib----------------------------------- Contractor's ------------------------- -- �.,/ Contractor's Name ---__L_ _ .C�'----------- -------------------------------------License �_ Phone _�3_ 5J Installation will serve: Residence rtment House,[] Commercial ❑Trailer Court ;j] Motel ❑Other -------------- 7--------------------------- -------of living units:_______ Number of bedrooms = -___Garbage Grinder __`_.. .__ Lot Size --_ _-^ ----_r•_____________ 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 plan, showing size of lot, location of system in relation to wppppells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if�li` sewerjs availab within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK°[� Size_ V 1/12 ___________ _7 X!- ._-._ Liquid Depth --T- ----- ---------- Capacity / ____ Type `_7 _ Mate ria IC�CWOT.-No. Compartments ______-_...... . Distance to nearest: Well _.� _--_________________Foundatfn _/ '40 Prop. Line ' 0 77 LEACHING LINE [� No. of Lines _________________ Length o/Beach/line___ l?__________.______ Total Length ( - __-_----_---___ 'D' Box _y_�._ Type Filter Material Depth Filter Material __ _ . �! / lip, .01Distance to nearest: Well —-------------- Foundation /10-------------------- Property Line �/Q-____-____--_--- SEEPAGE PIT [ ] Depth ----------- Diameter ________________ Number -----------.---------------- Rock Filled Yes ❑ No I❑ Water TaUe' Depth ------------------------------------------------Rock Size ---------------____ Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ....----.------------- 1 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------- -----------------------------------------------------------.----------------------------- ' Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- ----------- ------------ ----- -- _ r -- -- (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 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 i --------------------------------------- ------------------- -- BY - -------- -�--- -------------------------------------- Title 'V/41. __ �-/� �4�1/ (If of er than owner) a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- 0'----------------- ---------------------- ---- ----------------- ------ DATE ------ r�Zr-7 - BUILDING PERMIT ISSUED ----------------------------------------------- ------------------------- -- ---------- ------------------DATE ------------------------------------------- - ADDITIONAL COMMENTS --------------------- " -- -- ----------------------------------------------------------------------------------------------------------------------- - --------------- ------------- Final Inspection by: __________- -�-- Date -----+ - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1-'68 Rev. 5M