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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT f/ Permit No: . : (Complete in Triplicate) •-- -------------------------- p # : This Permit Expires 1 Year From Date Issued Date Issued - �_--� ---------------- --------------------------------------- - � 23s— `fes 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: /—TI .a CENSUS TRACT JOB ADDRESS/LOCATION - € Owner's Name ----------- --------------- ------.Phone Address -----=----- -- - -------------------• ----------------------------------------- City `` ---------------------- ------ ---t- --•-------- Contractor14 -•--•----- Name _J*,F_-y 1 ll� - License #l7 ---- Phone = ---- Installation will serve: ""' "Residence ® Apartment House f-7-Commercial-❑Trailer Court. '[D - +' - ' Motel ❑ Other -------------- ----------------------------- Number of living units:---I-------- Number of bedrooms ___(------Garbage Grinder/w_---- Lot Size - .X ©��---------•-•-- Water Supply: Public System and name --------------------------------•-----------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet Sand.❑ Silt❑ Clay ❑ Peat❑ Sandy Loam' ,ClayLoam.❑ Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type -------------c--------------- (Plot plan, showing size of lot, location of system in relation to wells;buildings, etc-.must be plpced on reverse side.] , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is avail;61e within 200 feet,) i Jr I ( L PACKAGE TREATMENT [ ] SEPTIC TANK Size- ---------------------- Liquid Depth J ----------------_-- Capacity AW;*--- Type No. Compartments ----------- ....All Distance to nearest: ell J0--------------------Foundation ` - --- Prop. Line-___5 -_------..--_-_f LEACHING LINE [�(] No. of Lines --- 0--- --- -- ----- Length of each line_ -V©-- Total Length ' ------ Q 'D' Box Pi--- Type Filter Material 100rtl-----Depth Fitter Material ---/1�_ -------.---._------------ --- „�,,«� Distance�to-nearest:-Well-==--: -----_-_-__-:.Foundationw7D-,--------__r-_. P-ropertyFLine--=---•-•---- i ,+r SEEPAGE PIT [ ] Depth ___------------ --- Diameter ---------------- Number --------- ---------------- Rock Filled Yes ❑ No I❑ Water Table Depth ------------------Rock Size -------------------------------- e Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------_--.- REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date ----------------------------------1 s 4 Septic Tank (Specify Requirements) ---- ----------•--- ------------------------------------------------------ --------------------------------------------------------------- DisposalField (Specify Requirements) -------------------------------------------------------------------------------------------------------------.------------ ----------- -------------- ----------------------------- -----------------------------------------_----------- -------------------------------------------------------------------------------- (Draw existing and required addition 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, 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 whichrthis 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 BY ---------- ------- Title -------------- ----- ------------------------ --------------------------- [lf other than owner) FOR DEPARTMENT S ON APPLICATION ACCEPTED BY ------ ------------------------------------- ------ ---'�- ------- DATE �` �--- ------ BUILDING PERMIT ISSUED .... ---- ------- ------------- ------ - ---------=-----°--------DATE - ---- ADDITIONAL COMMENTS -- ------------------ !_/ _7/. ---------------------------------- ----------------------------=-------- - -------------------------------------------------------------------------------------------------------------- - ---------------------------------------- ---- - --------- --------------- - Final Inspection by- ----- ----------------------------------------------------------------------- ------ ----- -- ------- --Date -- -- -- ----------------------- --- ------ SAN JOAQUIN LOCAL HEALTH 1STRICT E. H. 9 1-'68 Rev. 5M G