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FOR OFFICE U rF11 ,u APPLICATION FOR SANITATION PERMIT - ��Z-- •t Permit No. CY (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued ----------------------------- -_------------_,_--_---- Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5,49 and existing Rules and Regulations: JOB ADDRESS/LO ATION ------�----� -----------------------------` `�-�/ I j-0 -- -------------------------CENSUS TRACT -------------------------- Owner's -------------- - -- Owner's Name �0'C � ---� Phone ------------------------------------ Address � .� M,�: ------------------------------------------ City 1 --------/----------------- Contractor's Name License # _J a- Proneba-611-/4 -�---- - ---- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other ------------------------ ------------------- Number of living units _____ Number of bedrooms -_Z—Garbage -Grinder Lot Size -/Aa...A--- - ------ rr Water Supply: Public System and name -- -1- a_-_ ---- - -u— ----- ---------- - - Private ❑ f feet: Sand' Silt Clay Peat Sand roalay Loam ❑ Character of soil to a depth o 3 ❑ ❑ y ❑ ❑ Y ❑ Hardpan ❑ Adobe Fill Material __ -Of yes, type ---------------------------- z-A (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'[ ] Size-------------------------------------------- -- Liquid Depth,-------------------------- CapacitY -- ---------------- Type -------------------- Material---------------------- No. Compartments --------------- ------ Distance to nearest: Well ------------------------------------Foundation ------ -------- Prop- Line --------- -----,______ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_____________________'----- Total Length _________---__-_-________-_ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------_------------------------------------ Distance to nearest: Well ________________________ Foundation ------------------------ Property .Line- ____-____________._,_____ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth -------------------- ---------------------------Rock Size - ---- ------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .--_------------------ REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------------) Septic Tank (Specify Requirements) ------------ --- --- ----- ------- -I---------------------------- Disposal Field (Specify Requirements) ---- _ -- -------- - ---- ---- _ -- -- ,• ------------------N-------/- ---- - ------- `----------- -- ----- -------------------------------------------- ---- -------- ------------------------- ------------------------------ --------------------------- - ------ ---- ------------------------------------ -- ------------------------------------------------------ (Draw existing and required additio 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, Stat 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 .� Title ---------- ----------------------- (If other tha ow er FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - a ---------------- ---------------- DATE ----ko�9--�1-------------------- BUILDING PERMIT ISSUED ---- --------- -------DATE -------------------------- - ----------------------------------------------------------------- ADDITIONALCOMMENTS --------------- --- ----------------------------------------------------------------------------------- ----------------- --------------------------- --------- --------------- ---- ----------------------------------------------------------------------------------- ------------- - - - - ------- Final Inspection by: _ Date ----D "� 7------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M =: i