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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No ----------------------------- -----1---------- -------- (Complete in Triplicate) _- Date Issued --.�" �-`7�- This Permit Expires 1 Year From Date Issued Or a T 2t O— 39 all 2.0 7 i fo rein ,�J Q Application is hereby made to the San Joaquin Loc with county Nom549 and ex stln nR Ryles hRegulatioe work ns: described. This application is made ;n compliance �j,,f i�� --- ---- - ------ -- - ` 0^'4�`,�"""¢ Ccvw(1E VENSUS TRACT -------------------------- JOB ADDRESS/LOCATI h Owner's Name ---- -- ------- Pone --- ------ -��'T� . �..-----�„ '4--_ ----------------------------- Cit" ----- ---- ------- Address o , ��p��,,.� .'� - - -- Phone ------------ ----------------- ---------- Contractor's - ' License # -_I�r C- Contractor shame - . -� -- - -- Installation will serve: Residence ❑ Apartment H use❑ Commercial : Tra Court ❑ JV Motel ❑Other -0 Number of living units:----q----- Number of bedrooms _---- -_-__Garbage Grinder------------- Lot Size ----------------- ----------- ------- -------------------------------------------- Character ----- - _ ______---_-Private Water Supply: Public System and name --------------------------------------------------- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ N Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- 01 (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 public sewer is'available within 200 feet,) PACKAGE TREATMENT [ ] - SEPTIC TANK'[ I Size---------------------------------------- - Liquid Depth -------------------- CapacitY ---- --------------- Type ----------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------ ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Tota! Length th :- --------•-----------•---- ` 'b' Box ------------ TypeFilter Material --------------------Depth Filter Material Distance to nearest: Well --------------------- Foundation ------------------------ Property Line •---------- ------•_---- De Depth - Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No �J SEEPAGE PIT [ } P ------- ---------- Water Table DepthRock Size --__--------------------- ----- ------------------------------------ Distance to nearest: Well ----------------------------------- ----Foundation -------------------- Prop. Line _-_--.---------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------- ------- -------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ----------------------------------- -------------- ---- Disposal Field (Specify Re u;rements) __-__ 1.1,"— --- '"�"--� ---: = ------------------ - r . �.r---- ----v��--- �----- �f - ----------------- ----------------- --- --------- ------------------ (Draw existing and required addition 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: erson in such 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 Workman's Compensation laws of California." F Signed -------- --------- --- -- Owner - -------------------- -- - ------- ------- --- --___ __ =•- Title --------------------------------- By (If other than owner) FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY - ------------------------------------------ DATE - - ---- BUILDING PERMIT ISSUED ----------------------- ---- - ------ --- ---------------------DATE --------------------------- ---------•--- ADDITIONALCOMMENTS ----------- ----------- ------------------------------------- --------------------------------- -- ------------= ------------=------ ------------------------------------------ ---------------- V ------ ------------ ---------------------------------------------------------- --------�-------------------_- -- ---- Date '" ------------- ------------------------ Final Inspection by: -- SAN JOAQUIN LOCAL HEALTH DISTRICT r to 4 1-'68 Rev. 5M