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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: _. _ _._fz. • -------- - -------- - (Complete in Triplicate) --------------------------------------- ---------.--- -._ Date Issued This Permit Expires 1 Year From Date Issued Application is hereby made to the San Jo quin 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: • - __CENSUS TRACT _________________•- JOB ADDRESS/LOCATiO f- - f " -------------- Owner's Name - - --- -� - - ��------ ----- ---�------ -----Phone --------------------------- -------- Owner's Name .......City /1_11@__/�---------------------------------------------------- --------- Address ---- -------- -----------•--------- 711 Address ------ ems' ----------- ----------- ----------------------- ----- City 1� - ----on - w �i^f�.�l�- '� , ��-------------------•-- License # r _ _ _ Phane Contractor's Name ._--._ _---' Installation will serve: Residence Apartment House Commercial :❑Trailer Court i❑ Motel ❑ Other --------- ---------------t---------------- f � Number of living units:----/_._•_`Number,of bedrooms------Garbage Grinder _ _ ___ Lot Size __ __ --•---------- Private Water Supply: Public System.and name ----•'------------- - ----------•-- = 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 wells, buildings, etc. must be placed on reverse side.) y NEW INSTALLATION: (No septic p tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------- --- Liquid Depth -------------------------- 6N } --- Material-------- -----. No. Compartments ---------------- --- 1� Capacity ---- --------- ---- Type ----------- ----- rA ' Distance to nearest: Well --------------- ------- Foundation ----11 Prop. Line ________------•------ 1 _-- Total Length . LEACHING LINE [ ] No. of Lines ------------------------- Length of each line------------------- g -- Depth Filter Material ----------------------------- 'D' Box ------------ Type Filter�Matrial --------------- e . ._,. - Property Line. Distance to nearest: Well ---------------------- Foundation _.___.___----------- -- p SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No I] Water Table Depth ----------------------------- __---.-Rock Size -------------------------------- Distance to nearest: Well ------------ ------------- - ----------Foundation -------------------- Prop. Line ----------•----------- • _ f t REPAIR/ADDITION(Prev. Sanitation Permit# ------------- - - ------------------------ _---- i � D�iate�------- -------------------------- tsl -------------- - -- -- ----------------------- -- ------------ - -----------I- ------ Septic Tank (Specify RequiremenY ---f-- -------- Disposal Field (Specify Requirements) ---------- -------------------- .. = --------- ---------------------- -- --------------------------- ----------- (Draw existing and required addition on reverse side) 1 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:' "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." Owner t � [ Signed � ----- -------------------------------------- 1 ---+-------- ------------ ------ -- -- ------ -•------------------------------- By �. ----- --------------- Title 46 .--- --- -- A ther than owner} -•� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY :_�..- - ------- 41 -------------------------- DATE .__ './ ._� -------------- BUILDINGPERMIT ISSUED -------------------------------------------------------------•-------------------------------------------DATE � ---- ------------------- ----------•-- ADDITIONAL COMMENTS -------------- ------ ----------------------------------- ----------------------------------- -------------------------------=-------------------=------- ___________________________ ________ ___________________ ___________________________________________________________________________________________________________________ _ ------- --------------------------------------- --------- ____. _________ ______ __________ _____________________________________________________________________________________�[ !y ._. Final Inspection b C- ' -Date --------------------- ------ - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. - '` - ' • -