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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT n "Ilk --------- / -------------- Permit No.. (Complete in Triplicate) -J -n This Permit Expires I Year From Date Issued Date Issued - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 7 - - - - - - - - - - - - - - - Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein existing Rules and Regulations: described. This application is made in compliance with County Ordinance No. 549 and JOB ADDRESS/LOCATION ------ __J_0 --------------------CENSUS TRACT ---- 12F� ----------- --- --- -- -- ------------------- Phone 162y-- 7 Y ------------------ :;;w_ --- ---------- t ------ Owner's Name Address---- ---- ------------------- 454.120 - ------- city - - ---------------------------- ---------- 11 ---- License ------ Phone - --- --- ------ Contractor's Name _. --------------- - --- --- ------ 0 Installation will serve.. Residence Apartment Housef-] Commercial [-]TraiI& Court I Motel F-1 Other ---------------------------- 11 ----------- ---------------- 0 Number of living units.-,--/ ----- Number of bedrooms ----- Garbage Grind= ------------ Lot Size _A> ------------------------------- 9501 & Water Supply; Public System and name ---------------------- ------------- ------------------- -------------------------- Private E] Character of soil to a depth of 3 feqt:_$ond_'F_J_"'0, Clay Peat E-] Sandy Loom 0 Clay Loam.0 Silt '0E] Peat Hardpan[:] . Adobe g --Fill Material ------------ If yes, type -----_--------------------- (PI'ot plan,', showing size of lot, location of system in relation to- wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Ny epfi� —tank -or see-p-a-g—epit.permitte8.- if public sewer is available within 200 feetfeet,). 111. hi PACKAGE TREATMENT [J] SEPTIC TANK'{ "size ------- I ------------ 777� Depth A ---------------------- ------------- ------- --- , Capacity ---------- Type ---------------- `,__ MciteriaL__ 4c. =tl ---------- No. Compartments --------------- Distance to nearest -------- ------------ ---------------- Fouriclation ---------------------- Prop. Line -----------_ ........ IQ ------_------ LEACHING 4E No. of Lines ---------------- Length of each line-; ... Total Length - D' Box --------- �.._Typd-FilrerrMwefridl --- ....... &QthFilte'r-Material -----`-4-~-'4,,i---- - -- -------------- --- Distance to nearest: Well ------------------------ Foundation ----- z ------------------- Property Line _ -----•----------_--- De --------------_--- I I I Yes E] SEEP) Depth _. -- --------------- Diameter ---------------- N -umber I -------- z ------------------- Rock Filled No cir. Water Table Depth -------------------------- -- /I --------------- R -'_/--------- I ,ck Size ------- ----------------------- Distance to nearest. Well -------------- ------------ Fbundation -------------------- Prop. Line -- -------- REPA DiTiON (Prev. Sanitation Perm i t # --------X-- -------------------I------- _ Date ----------------I---,_-=-•_- -- -1 1 -------------------------- Septic Tank-ISpec'ify Rec�6ireiMlenWt-_-_--v� ------------------------- ------ - ---------------------- 2 ------------ ---- ----- Disposal Field (Specify Requiremeirtsfi ------ -- -------- vo ------- 4- "--- --------------------------------- 7; --------------- -----------------i - ...... - L �__eo ------ ---------------- I ------------------------------------------------------------------- I ----------- --------------- ------------------ C -------------------------------------------------------------- Draw -ex isti ng -a nd-requ i red -ciddi ti on on.reverse -side) I hereby certify that I have prepared this application and that the work -will be dome in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Reg6lations of -the San Joacin Local Health District. Home owner or licen- sed agents signature certifies the following: 1 Le- I . "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 Workm`an's Compensation laws of California." Signed------------- -------------------- ------- -------------- --------- Owner ---------------------------- By -------------- --- ------------- ---------- ----------- --------- Title ---- 41f other th owner) F PARTMENT USE ONLY APPLICATION ACCEPTED BY ------- -- ----- - - - - ------------------------ ------ ------------- ------------- DATE ---11=1, --_--76--------------`_ BUILDING -_--76--------------- BUILDING PERMIT ISSUED-- ---- - --- -------- -----------------------------------------------------------DATE-------------- ---------- ------------- -------- -- - --------------------------------------- :P-4 ADDITIONALCOMMENTS ___ _- -- - --------------- ---- ---- ---------------------- ------------------------------------------------- -- ----------------------------------- ---------------------------------------------- --------- ------ - --------------------------------------------------------------- J ------------------------ ------- ------------------------------ --------- - ---- ----- ---------- ------------------------------------------------------------------------------------------------------------------------ ----- --- ----------------------------- ------ - -- --------------------------------------------------------------------------------------------------- -------- ---------------------- Final Inspection by. - - ------ ------------------------------------------------------------------------------- Date ------ - 11=1,t7(5r-------- N JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1 -'68 Rev. 5M