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FOR OFFICE USE: ''. APPLICATION FOR SANITATION PERMIT ---------- ---------- ----- {Complete in Triplicate} Permit No. ` ---------- ---------------------- ----------- F Date Issued _ 77-�_76,s-/ ------------- ----------------_-----_---_---:.------- .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: a t e � .2...2. F=4-_-CENSUS TRACTJOB ADbRESS/LO TIONi(PtJ_>_ - _ :2� _y -- Owner's Na a -- tl - ------------ ----- ------------------------------------ = Phone rR Address �G A 3'�- _------ City -- _ -------- ----------------------------------------------- - � `' Contractor's Name - ------- License #�� t3 � Phone Installation will serve: Resid ce Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units ..... Number of bedrooms ________Garbage Grinder ------------ Lot Size _________________________________.____.---_ Water Supply: Public System and name ----------------------------------------------------- ------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Sift.❑1. ..Clay ❑ Pat❑ Sandy Loam Clay Loam:❑ p _ Hardpan E] -Adobe`'❑ %Fill Material ---------- If yes, type ---------------------------- � A (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,] PACKAGE TREATMENT [ SEPTIC TANK.( ] Size----------------------t__ _---"----------------Liquid Depth --------------.------.----- " 1 Capacity -------------------- Type ---------------- -- Material-A-f`----------------- .No. Compartments -----------------•----- Dis Y ------------------------ Len th of each line ___________ ________ prop. Line -------------_- _---•- LEA -CHING LINE Not of Lines ance to' nearest: Well ___ Length Total Length ____________________________ D' Box " ""Type Pilfer Material" ___.______-_.Depth Filter Material -----------------1-1----------------- ---• Distance to nearest: Well _______________________ Foundation ------- ---------- Property Line ------------------------r SEEPAGE PIT [ ] Depth ------------- ------ Diameter ---------------- Number --------------------------- Rock Filled y Yes ❑ No i❑ Water Table Depth ------------------------------------- ---------~Rock Size ;------------------------------ Distance to nearest: Well -----------------------------------+---Foundation -------------------- Prop. Line --------- ------------ y 4 REPAIR/ADDITION(Prev. Sanitation Permit�# -------------------------------------------- Date --------------.------------------- ) Septic Tank (Specify Requirements) -------------------------- I DisposalField (Specify Requirements) ------------- - -------- ------------------------------------------------------------------------------------------------------- ----------- ----------J/------ - _ - (Drawlexisting-and.required addit on on_revers'e.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 which this permit is issued, I shall novemploy any person in such manner as to become subject to Workman's Compensation laws of Califoinia." Signed _, ------ ------------------------------- Owner BY --------------------------- Title __.. -- -- Ilv----------------------- ------------ (if other than owned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - ---------------------------------------------------- DATE --------------- ----------------------- BUILDING PERMIT ISSUED -------=--------------- ----------------------------------------------------------------------------- ---DATE ------- ------------------ ----------- ADDITIONALCOMMENTS ----- -=---------------------------------.----------------------------- - ---- --- ----------------------- ------------- ----------•--- -------- ------------------------------------ ------ --------------------------------------------------------- -------------------- ------------------------------------------------------------ ---- r ----------------------- ---------------------------------------------------- -------- -------------------------------------------- ----------------------------- -------- - ------------------------------ --- ---- - Final Inspection by: - . Date y _.ate- SAN JOAQUIN LOCAL HEALTH DISTRICT , .z E. H. 9 1-'68 Rev. 5M