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FOR OFFICE USE:, r . - APPLICATION FOR SANITATION PERMIT Permit No. -- ----------- --------- ------------- (Complete in Triplicate) . ---------------------------- ---------------------------- -------------------- ------------------------------------- Date Issued__.._._-_-__________-___-- This Permit Expires 1 Year From 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION e9"_-_ _ �,? -'---'_. _�:. Urus TRACT ----------------------- + Owner's Name .._�_y- >, �/'C - ---------------------------Phone ------------ - - �l [�'-61�+d�y/t�--�--- --��- - - - - - ��--� - ------------------- Address '�` _.. � ------------------------------- -- City Contractor's Name . t� 'f' � ' Lice nse #,,A*'7 f Phone Installation will serve: Residence ❑Apartment House-[] Commercial)Trailer Court TO ` Motel ❑Other -----------------------------------------I--- IJ Number of living units:_.--. Number of bedrooms __!-�---Garbage Grinder _ '_.__ Lot Size Y-r ' - _-_----_- Water Supply: Public System and name ----------------------------------•---------------------------------------•----------------------------------r PrivateX Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat E] Sandy Loam -❑ Clay Loam 'E] Hardpan E] Adobe E] Fill Material ------------ If yes, type ---------------------------- (Plot --------_--- _--_-__--(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,l -' PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ___---.---_-._..__-.-.-_. 1 Capacity -------------------- Type --------------------- Material-------------;-------- No. Compartments --------------------•• V Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------:_....... %I LEACHING LINE [ j No. of Lines --------- -------------- Length of each line---------------------------- Total Length -___-_---__.-_-_---_----_--- d � 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------- ............ j Distance to nearest: Well ---------------`-------- Foundation -.------------_- ------- Property Line. ------------_--_----- SEEPAGE ----_----. SEEPAGE PIT Depth s ------ Diameter 41----------- Number __lam-------------------- Rock Filled Yes M No iG Water Table Depth --- Rock Size�� _ _ = --------- Distance to nearest: Well -_ r ---------------Foundation ------- Prop. Line __._._ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ Date ----------------------------------) Septic Tank (Specify Requirements) ------------------ j---------------------- Disposal -------- --- Dis osal Field JSpecify Requirements) - < � ------------------------------------------------ ------------------------------------- -- -------------------------------- -- -------------------------- ----------------------------------------------- ----------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that then'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 tFie 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 ---------~-`----- -- -------- L Owner BY I Title rim` . Ze ( ) - ---- - r l er than owner r. E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ' DATE ..-- Z---- --------------- - BUILDING PERMIT ISSUED --- ---------------- ------------------- --- ----- --------- ----- ------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------------------------------------------- ------------------------------- -- --------------------------------I----------------------------------------------------------------------------------------------------- --------------------------------------------------------------•- ---------------- ------------------- t Final Inspection b --------------Date ----- ------- --- ------------ ------- # SAN JOAQUIN LOCAL HEALTH DISTRICT k a E. H. 9 1•'68 Rev. 5M 41',"