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LFOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Q/ Permit No `� ? ....... ----------------------........----- (Complete in Triplicate) r P Dare Issued ..II..-.��73 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 'th County,Ordinanee Na. 549 and existing Rules and Regulations: - -------- -------------------------- _...,....CENSUS TRACT -----------••••------- JOB ADDRESS/LOC N .- jam/---------- -- Owner's Name ... P� t .......... -----Phone------------------------------••---- �1 Address ✓'�`- • . - -- - - - - .......�C. . '-----'--- -'--'--- --Phone .......-.............. ---- -- cit .. Contractor's Name !G�r!cs t -.. License # /.��!3- Installation will serve: Residence partment House Q Commercial oTrailer Court ❑ Motel Other-- --------- -------------- /7W.V�a' 71.�r.P.a-- -- ' 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•n -Silt E] Clay Peat E] Sandy Loam 0 Clay Loam,❑ Hardpan ❑ Adobe❑ Fill Material ----.- If yes,type ._...----.- _------------- (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 I ] Size-------.......................----------....•.-- Liquid Depth ..._..._........... ,---•- Caaci ...... .Type-_----:-------------- Material................. ./No. Compartments ..................--•- Pb-- '----- Distance to nearest: Well ..... -' .................•------------------Foundation ----....----------..-. Prop. me ........--•---• LEACHING LINE [ ] No. of Lines .----------- Length of each line..... .- Total Length :........................_. 'D' Box ------------ Type Filter Material ....................Depth Filter Material ----------------------------------------- Distance to nearest: Well ...... Foundation Property Line ........................ SEEPAGE PIT [ ] Depth Diameter ................ Number Rock Filled Yes ❑ No WaterTable Depth ---------- ---------__ ............•....--Rock Size ----------------_------------• Distance to nearest: Well .................Foundation ....................,Prop. LIM REPAIR/ADDITION(Prev. Sanitation Permit# ...............-----------------------_:... Date ---------_-----_--------...... 1, r' .. i Septic Tank (specify Requirements) _..............................:...rr ` r e Disposal Fi d (specify Requirement - - - --------- -- -^---"'-• .'j'"`A -- 3 (prow ex ting and required ddition 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 which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's CompensationRlsof California.,' Signed ....... ....... .._ .. ..------. OwnerBy ......... .. ...------ "-- ------------- Title 7-- a' --------------.............----- (If other than owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. .... ...... ..ry 1 l73 - :L,. . __ .._.... - - ..- -------- -..... - --"-----. DATE .:...�.... .------------------------- BUILDING -- -- - -- - 'BUILDING PERMIT ISSUED ................ ..'------------------------------------........ -- ....................... ---DATE ------------ ---.....__..••--•---------- ADDITIONAL COMMENTS .................. -----------. --------- -.0.0--_.----- - - - ".............---- .... --- i^.' j�........._...-- .......... .-'----- - Date D - Final inspection by: ... .. � --- > --- - ------ .... ..... SAN JOAQUIN LOCAL HEALTH DISTRICT '