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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Fi, T 7�7�V 7 --------------- -- ------------•--------------------- (Complete in Triplicate) ..----Permit No. ....._.... - ----- ? a-Z v + X This Permit Expires 1 Year From Date Issued Date Issued - --_ _-___�__. Application is hereby made to the.San Jodquin 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: }�y � S10 _/ -CENSUS ' • JOB ADDRESS/LOCATION ._.: _ L ----- --s.............. .. - - /---1----I =--------CENSUS TRACT -------.------•-•-----•-•- Owner s Name -_1 = C ---------- -----------------_Phone ------------------------------•----- Address .-----------•------- --- --•--[------w `- City r __.. � -u`� License #c .11 �. _.._. Phone - ------------------ Installation ------'� Contractor's Name ___ __ .�{ - -w----=xs1-- -- Installation will serve: Residence J;. partmeht House[] Commercial:❑Trailer Court i❑ 1 - Motel ❑ Other _______________ ______ Number of living units------------- Number of bedrooms __Garbage Grinder ___ Lot Size _,� �r _._....____ ---------------------------------------- t� Water Supply: Public System and name ______________________ {-- --••-----------------•--------------------Priva Character of soil to a depth of 3 feet: Sand ❑ Silt Clay ❑ Peat�] `Sandy Loam ❑ Clay Loam.E] Hardpan ❑ Adobe Fill Material If yes,type _--________________________ F (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 ize._-__ - ..-_________ Liquid Depth ---------- F II •. Capacity -----3_�'� _ Typ fS ....... Materia ._ Compartments ______�,--:.... Distance to nearest: Well ----;0__¢____________________Foundation -.___ ��'..+�___.. Prop. Line -:__ts...L.,.__--- � F. i LEACHING LIN]: No. of Lines $ ----------- � __. Length of line____-__ -)- otal Length .- ........... 'D' Bax Type Filter Material __ �.-__-_.-.Depth Filter Material 4-f- _-___._.a--------------- ----------------- .............. { Distance. nearest: Well _�- _____--_ _ -_ i :-.. Foundation s ----- =--- ---- Property Line . _ .... :.: SEEPAGE PIT ['' ; Depth __ �--�_:-___-_ Diameter _53-------- Number --------- -------- Rock Filled Yes M,-�o .c Water Table Depth __-------- •-------i------- -= Rock Size _ �k- G Distance to nearest: Well --------j.- t-----------------------Foundation ._.1-0------------ Prop. Line . ............. �i REPAIR/ADDITION(Prev. Sanitation Permit# -•- ,--------------------- Date ---------------_-.--------------I Iy Septic Tank (Specify Requirements) -------- ------------------------------' -------------------------------------------------------------------------------- ---------------- IDisposal Field (Specify Requirements) --- -------------------------------------------------------------------------------------------------------------- -------------------- --------------- ---=--- -----= --------------- -----------------------------------------------------------------------------------------'--------------------------------•- ---------------------- ._w. i (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 j 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: Fiji "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 Workman's Compensation laws of California." Signed ---------------- --- w _ 4 L B If other t a.n y ------------------------ ------ Title Y _ j ( caner) FOR .DEPARTMENT USE ONLY l J APPLICATION ACCEPTED BY -QK*T - ----------------- --- DATE ---- ° �_.-....----- BUILDING PERMIT ISSUED ..... .. ................•---------------------•-•-----•--------------------------------=--------- DATE ------------------- ------- ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- --------------------------------------_--------------------------- V - F11 100 -A_&&�A_ --- ----------- ------ --- - ---------------=--------------------------------- ----- ------ FinalInspection by ------------------------------.------------------------------------------ -------.Date ----- --------_------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 3