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FOR OFFICE U E- ,- ' �' � APPLICATION FOR SANITATION PERMIT Permit No.�� ' f ___-_ L(Complete in Triplicate) ------------- 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 is made in�corn lianc, with ounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION / J--- ---------. ----- - - Re_-12--,----- -------------------------------CENSUS TRACT -------------- ----------- Owner's Name ------ -_ i `--------- - ------ Ion + = Addressf" _ City 12-� r 4.� p Contractor's Name -------------------- ---- --------------------------_- -__.License #/ /1--------- Phone __ �j-t---(__1d__7 Installation will serve: Residence Apartment House,❑ Co nercial :❑Trailet Court in Motel ❑Other ------------ ---------- Number of living units:_= Number of bedrooms ___ Garbal � ` � ge Grinder ------____-- Lot Size ---- ------ .-to - -------- t Water Supply: Public System and name ----------------------------------------------- -----------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Cla TPeat❑ Sandy Loam .0 Clay Loam ❑ Hardpan E] 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,) C PACKAGE TREATMENT [ ] SEPTIC TANK Size------- ---------- ----------------------------- Liquid Depth ----- -------------------- UI �~ Material ` Capacity ---------------- Type -------- No. Compartments ------------------------------ - Distanca Fo nearest: Well - Foundation --------'-----�- _---- Prop. Line ---------------------- , 14)LEACHING LINE No. of Lines I-_ _ Lenth of each 'line_ Length -------------------- --- - Total Length 'D' B'ox -------- --- Type Filter Material --------- -- -----Depth Filter Material --------------------.--_-----_--_-_---•---•- Di stance to nearest:;Well ----_----_ _ ________ Foundation -------------- --------- Property Line SEEPAG8)PIT ] Depth ____I-------------- Diameter ---------------- Numberl--------------------- ----- Rock Filled Yes '❑ No .0 Water Table Depth ------------------------------------1-1------Rock Size --------------------------------- Distance ------------------------------ Distance to ne rest: ;Well ---------------------------- - -------Foundation -------------- ----- Prop. Line .---------__ REPAIR/ADDITION(Prev Sanitatiori�permit# --------___________ `'__-_- ----- Date ______ 3 Septic Tank (Specify Requirements) ------------------- ----------`-------------------.---------- -------- .1y ` = O t R .. t Disposal Field (Specify Requr. ent6) -----------___________------� __ _ _____ - --r- ---- --- -------------- - a ,, ; __--_______ = _ _ .• Y t ---- --------- =X ---- ------- -------------------------------------=------ ----------------- Draw existing and required addii1'861 ri reverse side) ` I hereby certify thatti have prep aredthis application and that the will be done in accordance with San Joaquin County Ord inances,TTStote7L'aws,-.arid Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifi s4he ollowing: s ; "I certify that in the performance o0"?he work for which this permit is issu.iid, I shall not employ any person in such manner as to become sub[ect to Workman`k-Compensation laws of California." j 1 �_._ ' Signed ------�- —�—= --�- --=_ -z.-- ---,_ - -- Ow.ne f --~ r BY ' s r --------------------------------- Title r - f of than owner,� �{ r FOR DEPAitTMENT USE ONLY + ; APPLICATION`ACC PTED BY b ---- - ----------- --------------------------------I ........... DATE -----3�- A -10. ' BUILDING PERMIT ISSUED -_ --2----------------------------------------------------'-8---------------------- DATE•------------------------------ ADDITIONAL COMMENTS ------------ I--------- -- t�:._ , c ---------------------------------------------"-,- -- --------------- `---------------------------------------- `�•1-------\"----------t ----------`--------- --------------------- • -- - ---------- - ------ 4 t ------------ -- ------------------- -- ------------------ - Final Inspection by.. ---------- = Date SAN JOAQUIN LOCAL HEALTH DISTRICT ' E. H. 9 1-'68 Rev. 5M