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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit. No. ------------- ------•---- �� 7 ------------------- This Permit Expires ] Year From Date Issued Date Issued ------ ---------- Application ---- ----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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...a _.-. .J''' � �.j" .g. CENSUS TRACT ... ......... Owner's Name ( --- : Y sr - 3 ----_---------------r---- ------- ------_.Phone ----•.-..-..-.............. --••---- Address .. . ..e. tr"..._ �'�---- . ., ...._.. City ----- —"C ' . t f Contractor's Name ...__ hone _..... ............. : ..... .License # p _-��-;_ M._r�.. .- - Installation will serve: Residence ( Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ---------------------------------- --------- Number of living units:-------1----- Number of bedrooms ___-2��Garbage Grinder _.. Lot Size ------ -------------------- Water -- -^----_ -Water Supply: Public System and name ....--•--------------------------------------------------------------.. ------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ .Silt❑ Clay ❑ Peat❑ Sandy Loam e Clay Loam ❑ Hardpan ❑ Adobe [] Fill Material ............ If yes, type --- ------------------------- (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) d [ ] SEPTIC TANK Size_. 1 ..._--_------------- Liquid Depth --------- ._........... PACKAGE TREATMENT ,,. $ Capacity 1,1.. e�Wil.-- Type Material.: '"-_4_-X ...... No. Compartments Distance to nearest: Well ______ ----> :�.� ,,.: :.......Foundation .._dZ2,,2, ' _ Prop. Line ..... LEACHING LINE [)j No. of Lines ------------- Length of each line---- -� --------- Total Length __.n.Z4;/ ---_-• ...�:..:� - D' Box ----- ------- Type Filter Material .... ....... P Material --------Y.1..........-•--•......----• w; Distance to nearest: Well ------- o undat on }�../' '__.._.. Property Line ._._ ......__ Depth _,�,lfo ..... �iarrsete�,.�...,�'F,�.��._. Number ---- •--�------------------ Rock Filled Yes ( No C3 Water Table Depth ............. _' --,------.--------Rock Size Distance to nearest: Well _-____ _ _ _ ________________Foundation _ __.,. Prop. Line ..... __ _�_._.__ REPAIR/ADDITION(Prev. Sanitation Permit# --------- ----------- ------------ Date .................................. SepticTank (Specify Requirements) ---------------•-- -----•--------------------------------•----...........--------•--------------•••----•-••----------•-•----------_........ DisposalField (Specify Requirements) ---•-------•------•-••---------•---•---------••----•---•-------•--------------•• -•-------....-----------------.------••---------•-- --------•---------•.................................. ---------•-------•---•-••--•-------------------------•----------•-•----•--------------•--------------.....__.......-----------------------•-----•- (Draw existing and required addition on reverse side) 1 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 Hcen- sed agents signature certifies the following: "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 ----•-•--•--•---- Owner y By • _..- _ - .._ _.� �' .. . ------------------- Title _.�� ° :•_ ; s -.-... ----- - --------- .. .. ----- (If 0t6r than owner) FOR DEPARTMENT USE ONLY Y APPLICATION ACCEPTED B 4' �'--------------- DATE .:�`��? a� " AL1................ PERMIT ISSUED ----------- --------------------------------------------------- -------------------------------------".... DATE _.........._... ---------------------- ADDITIONAL . .COMMENTS ................................................•----•-•---------.._................................................................ -------------------------- ------------------------------------ ----- -------- ------------ " � ------•----....--.-------------------------------------------._-...._-..------- ------•----••-----�-�- --------------------- .. ....... Date .fFinal Inspection bY; . �--- --- - -- - SAN JOAQUIN LOCAL HEALTH DISTRICT � - -- •F 4 7/. - -•- - -._ -� fin � ..