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FOR OFFICE USE: "Tg . —APPLICATION FOR SANITATION PERMIT ------------------- (Complete in Triplicate)r Permit NoA:_1__ __. -------- ------------------------------------------------ This Permit Expires 1 Year From Date.lisued 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 compliant 'th C unty Ordinance No.5,49 and existing Rules and Regulations: i JOB ADDRESS/LO ION -�-�,----------�---- - ----- ---- ------------------------- ----------CENSUS TRACT rZl' ----------- .- . --!-�- r Owner's Name ...............---------------------------------- -------Phone --------------------------- AddressC ---------------- City ----------------------------------------------------------------- •--••-- _, i- ZC f Contractor's Name .---- License #/ ._!12-Phone ---- - -- Installation will serve: Residence Apartment House'❑ Commercial :❑Trailer Court Cl Motel ❑ Other ---- ------------ --------------------- ---- Number of livingunits:---- ----.__ Number of bedrooms Z Garbage Grinder V ------- 9 .�- --- Lot Size _44------- ----- --QA---•--- Water Supply: Public System and name -------- ---------------------------------------------------•---------------------- ------Private Character of soil to a depth of 3 feed: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material w __ If yes, type ____-________________-__-_ (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 uupublic sewer is ovataJ?le within 200 feet,) ~ PACKAGE TREATMENT { ] SEPTIC TANK[ iza_ �!_ ______--_- __. Liquid Depth _._ �.�-------- Capacity ,-_-__ Ca acit .�lA.____-,__ Type _ _.__: [ Material �_p No. Compartments _v�/ _. p Y - -- Yp �-- - -- [.� Distance to nearest. Well ______ Fou-ndation _ ,__� ---------. Prop. Line __ _____-______ l LEACHING LINE [ No. of Lines _______ ________________ Length o each ine__ __r�_�_-__!____--,____ Total Length f_U� / F +� t ' 'D' Box -41,6 _ Type Filter Material � ____________ pth-'Filter Material .__ j___....____ �fA - ------------ Foundation' D� c to nearest: Well ___ __ � ._..L______ Property Line_ _-____ ---------------- g-1 _______________1___________ Diameter , _Number -____-____ _ __ Rock Filled- Yes No //__ Q� j �a Water'Table Depth -------lf 11 ---------------Y-- - --------Rock Size --1-,?--, ---------------- Distance to nearest: Well ________________________________________Foundation `------------------ Prop. Line ..........------------- REPAIR/ADDITION ___.__ --_REPAIR/ADDITION(Prev. Sanitation Permit# - ' _______) �.._r....:. -------- ---------- ---------------- Date --------------------------- Septic-Tank (Specify Requirements) ____________________ l : Disposal Field (Specify Requirements) ____________ i ------------------------------------------r------------------------------------------------ ----------- - -_----_------ ------------------------- -------------------- r {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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------------- ------ -----------'-- ---- OwnerBY ---- - tilEZ� ----------------- Title . .. (If r owner) FOR D16 RTMENT USE ONLY rr I APPLICATION ACCEPTED BY -` DATE i f BUILDING PERMIT ISSUED -------------------- ----- -- ----DATE -------- ---------------------------------- ADDITIONAL -- ------ M ---------------------------------------------------------- ADDITIONAL COMMENTS -------- --------------------------- -------------------- ------------------------------- ---- -------- ---------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- -- ------ - -- --------------------------------------------------------------------------------------------------------------------------------- ------------------------------------ - ----- - ------------------------------------------------- ----------------------------------------------- ---------- Final Inspection b __ ___ __ __ _ __ _ _ _____________Date _____-__ p Y- - -- - --- ---- -- -- -- - - - JOAQUIN LOCAL HEALTH DISTRICT �-�-� - ---�1�.-�--� * f;