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FOR OFFICE USE: ti Cs �� f APPLICATION FOR SANITATION PERMIT - ------------------------------- ---, (Complete in Triplicate) Permit No. --- M ---------=- -----------------•----" ---------------.- __.--_:______ This Permit Expires 1 Year From Date Issued Date Issued _l-. =_w- 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION',.- 1-T-I'L--- : `3 /� -°� I/�-! /f3..CENSUS TRACT Owner's Name -�c`a-" �j c, q' ,� ��p "4----- Phone ------------------------------------ Address � -- �� -------------------------------- City -- - -------- Contractor's Name '� �---------------------------------------------------------License # �� Phone t!A4 } 'Installation will serve: i Residence ❑Apartment House❑ Commercial.❑Trailer Court f: Motel ❑ Other Number of living units:-.-/ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ____________________________________________ Y - �/f Q f / v Private ❑ Water Supply-. Public S stem and name __. ____ Character of soil to a depth of 3 feet. Sand' ilt❑ Clay ❑ Peat❑ Sandy Loam .F] Clay Loam.E] Hardpan ❑ Adobe;❑ Fill Material ------------ If yes, type ---------------------------- ' (PI'ot 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,] Q PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------- ----------- Liquid Depth ------------------ Capacity -------- ------------ Type ---------- Material---------------------- No. Compartments --------------- 'i ....... Dstance to nearest: Well ------------ _--_-------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE { ] No. of Lines ------------------------ Length of each fine---- ----------------------- 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 i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- A Distance to nearest: Well _________________________---__-_ _Foundation --------------- ---- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________} Septic Tank (Specify Requirements) ------------------------------------------------------------- --------.-- ------------------------- Disposal Field {Specify �'Requirements) � _:- !_4 _ /_ +?fes -t---------------" C '(.-- - /----- --- ---------------------- r cj " 1 , ' f'� - �r-�=`-�-------------------- -/ y --- ------ ---- -- -------- . � ------ ------ --- - ------------------------------------------------------------------------------------------------------------------------ iI (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 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 asto beco e sub Wor an's Compensation laws of California." Sig ned :_17� - tom" 7---------------------------------- Owner BY ------ - - --f — --------------- Title -------- ------- - other than owner[ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ �J -� ---------------------------------------------------------------------- DATE -------1 '1= ----------------- BUILDINGPERMIT ISSUED^--------------------------------------------------------------------------- -------------- --------------DATE ------------------------------------------- ADDITIONALCOMMENTS !-------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ------------------ �-�------ ---_------------------------------------------------------------------------------------------------ ----- -•------- ------------------------------------------ Final Inspection bY- ----------- Q'�ae�°'i.------ -----.-.Date -----1--(�--�lJ-------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68.Rev. 5M