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FOR OFFICE USE: � - APPLICATION FOR SANITATION PERMIT -------- �.-------=----- = y Permit No.(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 compliance with County Ordinance No. 519 and existing Rules and Regulations: JOB ADDRESS/LOCATION -_�-`-� --------------CENSUS TRACT -___;.___.___-___-_..._- o �.. 4 Owner's Name �T Jho ---------------- ._Phone �� Address _. � .� ---------------------------------- ---•-----------------------------:. City -----------------------------�-)oTK-----j s LIYI®_k_k?----- Contractor's Name ----.-a�--------- -- ------.License # ------------------------ Phone ------------------------- I— Installation will serve: -Residence>(Aartment House Commercial :❑Trailer Court si❑ 1 Motel ❑ Other ---------------------- -------------------_ Number of living units:.__.1.___-_ 'Number of bedrooms _ ______Garbage Grinder ©" Lot Size "_< _- _______________ Water Supply: Public System and name ---------------------------------- r r , •- --�-----------------------• -------1f-----------•-------•---------------Private Character of soil to a depth of 3 feet. Sand'❑• Silt❑ Clay;❑ Peat ElSandy;Loam •❑ Clay Loam ❑ { ;Hardpan ❑ Adobe be Fill Material ____ If yes, type ____________________________ i r (Plot plan, showing size of lot, location of system i'h-r6lation 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 T ] Size----VZO----GA..---- ----------- Liquid Depth -------------------------- Capacity -------------------- Type -------------------- Material--------------------- .No. Compartments -------------------_ Distance to nearest. Well ------------------------------------Foundati� ---------------------- Prop. Line ----.--------___------ Gk LEACHING LINE [ 1 No. of Lines -At __________ Length .of each line._.___ -------,_____-Total Length-.-_- �o- 11 'D' Box _. ___ Type Filter Material .Depth Filter Material ------- _-___-__._____________________ Distance to nearest: Well _--6- '0. Foundation __�0� ------------ Property Line __sr.?_1'"E'_____-_-___ SEEPAGE PIT [ ] Depth ____________________ Diameter ----------- ---- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------------------••- -----------Rock Size ------------------ Distance to nearest: Well ________________________________________Foundation ____________________ Prop. Line ....____--___________- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ______________._-________________) •I�x -4: Septic Tank (Specify Requirements) ------ -------------- ---------------------- ----- Disposal Field (Specify Requirements) -----------_------------------------------ - � .. ------------------------------- -------------- -------------------------------------------- ----------- . ----------------------------- -- -----------------_------------------------ „=,_ raj ----------------------------------------------------------- ------------------------------------•---------------------------------------------------------------------- ---------------------- .� (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 1 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen - ,; sed agents signature certifiers the following: I certify that in the performance of the work for which this permit is issued, I shall not employ any person-lin such manner as'to becom �ctorkm mgensati. laws of California.Signed'x __ Owner BY ----- ------ -- -,--------------------------- - ------------------------------------------------------- Title ------- -------- "�,(If other than owner) t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- --- ------------------------------------------------------------------------- DATE r ------------------ BUILDING PERMIT ISSUED ----- ----- --- --- -----DATE ----------------------------------- A ITiO Al O��y M TS _. ------- -----:------ - -- .................. fifi�� p�,,,� ��14�----Z-,7 'A Ah L ------------- Final Inspection b � "'-------- --------- ------ --"Date __-.. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 i-'68 Rev. 5M a -� C