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:•:- `FOR OFFICE USE: �a � '�' "� �•„�..a,�� APPLICATION FOR SANITATION PERMIT ---------------- .----•------ ------------- (Complete in Triplicate] Permit -------------- ► ¢-. -------- ------------------ --------------- ------.- This Permit.Expires 1 Year From Date Issued 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 js made-in compliani7 ce ith County Ordinance N 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N d . CENSUS TRACT Owner's Name - 1 t q , - - - -- --- -- --Phone -- ----------------- end --�}--�---- Address/,�_70 ----- �' - City --------------- r- -----------------•- - Contractor's Name ----_ -- -------License # . s (7 ZW_ ❑ - - -- ---- - ----- Phone - --- Installation will serve: Residence [<partment House Commercial ❑ iTrailer Court '❑ Motel ❑Other ------ --------------------- - - -- Number of living units:_-__--__.- Number of bedrooms -----Garbage Grinder --.---_____ Lot Size -,_ -�-� t --------- Water Supply: Public System and name --------------------------____- -.- - - ------- --------- -----------------•-------------- -- -------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑,- Peat[] Sandy Loam -❑ Clay Loam Wi Hardpan p Adobe E] Fill Material -----__---- If yes, type -------------------------- - (Plot plan, showing •size of lot, location of system in relation to wells, ` Y 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,) PACKAGE TREATMENTr C ] SEPTIC TANK:[,] Size------------------------------------------------ Liquid Depth --------- -'`•-------- 0 Capacity ---------------- Type -------------------- Material.-- No. Compartments ----- t..,i : .� --------- Distance to nearest: Well. ----------------------------- I ------- - ------------ -- -•_______Foundation .__- - - - - --- --- Prop. Line ---- ----------- LEACHING LINE [ ]: No. of Lines ------------------------ Length of each line----- Total Length -�____---__ --- D' Box --- - T Type Filter Material ------_---_------_.Depth Filter Material -- Distance to nearest: Well ----- ------------------- Foundation ------------------------ Property Line.----C]------No EPAGE PITDiameter .�_ [ l Depth --- --------------- --------------- Number --- - --- ------ - -------- Rock Filled Yes 0 Water Table„Depth ------------------------------------------------Rock Size ----- i Distanceto nearest: Well --------------------------- Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation„Permit# ----------------__--_- -- --------------------- Date Septic Tank (Specify Requirements)--_----- --__- -------------- Q L -- - '� S:--- ,(Draw existing and required addition on,reverse side) ] I hereby certify that ! have prepared this application and that the work will Rbe done in accordance with Sara Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed ; sed agents signature certifies the following: h "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 be e s 'ect to rk 's'Compenata ' n laws of California.” t Signed _L,-- --.-__ -.G _----{-- _ a �� ` '_ �— -------- Owner By',,`=------------ Title l - - ---- - - - ---------------- (lf other than owner) �� -------- - -------- ------ - FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY 77'�f:j -- __ € r�_ 'f - y ----------------- - ----. DATE ----- ------ BUILDING PERMIT ISSUED ----------------i___-_ -� ---- -�------ -- -------------------------------------------------------------- - DATE . ADDITIONAL COMMENTS --------------- -- --------1-i -------- ------------------------ ------------------- ------------------------------------- --------- ------------------------------------- ----------------------------------------------------------- ---------- `- f -------------------- ------------- - - - --------- - --- ---------------------------------------------------- Final Inspection b j - p Y ---- - afe -- ------------- ------------- ------ ---- SA JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M i