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r FOR OFFCC" ' x APPLICATION FOR SANITATION PERMIT Permit No. ~/ ----- --- ----------- {Complete in Triplicate} ------------- -------------- ------------- / -I D ---------------------------------_------_--_----------- this Permit Expires 1 Year From Date Issued Date Issued _____________----- 7/ `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. 349 and existing Rules and Regulations: JOB ADDRESS/LOCATIONF '---_----_ Phone T -------------------------- Owner's Name ------- - �� -------- ---/__D�--:�`(......... -�-- - - �=��_�- - ----,��Q Ems- --�-�$------- -- -- - CENSUS TRACT Address ------'------------ 1r '= 'j�{i'----------iff:--------------------------------- Cit- ------- ----------------------------------- Contractor's ----- --------------------•---Contractor's Name ------<1111--c 14--cs-------I?-.-.------0-cc-it-x --- ----------------- - ------ Phone --------- Installation will serve: Residence [Apartment House❑ Corr`imercial'❑Trbiler Court Motel ❑ Other ------------------------------------------ �. i 1 �; ^ � _ � Number of living units:----/------ Number of bedrooms _______Garbage Grinder ---- ------- Lot Size ___/G_� �_.f2�____._.'____.______ Water Supply: Public System and name ---------------------------- - 1 ------- ------------------Private Character of soil to a depth of 3 feet: Sand'[ Silt❑ Clay 0 aPeat❑ Sandy`Loam❑—Clay'Loam 1:11 Hardpan ❑ Adobe ❑ Fill Material ----------- If yes, type_________________ _______ i (Pl'ot plan, sowing size of lot, location of system in relation to wells, buildings, etc''must 'be placed, on reverse side.) 1 ' f eet,) O NEW INSTALLATION: (No septic tank or seepage pit permitted if public ewer is available within 2�e fthi �- -� PACKAGE TREATMENT [ ] SEPTIC TANK,[A Size__________________!______,. _ ____ LiquidP� I Capacity &`! ._ -- -- Type p' x a f Material_ Ca_vmC_.__ No, 'Wnpartments- -------- Distance to nearest: Well .:.``----- - ------ --------Foundation i - LEACHING LINE [ ] No, of Lines. _____.. ---__.__ Length'of each line----- 5 �-_ Total Length` ._ ld°______�{....... w 4 2�r, ------- D' Box . _ �_y. Type Filter M�nall�f�--_-Fo�undat�n th Filter Material Property!.�i•-�---•----------------------- [ } p meter ---- Number -------------------- ------- Rock Filled Line r. ----------- --- ---- SEEPAGE PIT}. Depth to nearest. Well � � �� ', Yes'`'[] No i❑ /xJ Water Table Depth ------------------------------------------------Rock Size ----------------------------------- Distance ----------------------- -- -- Distance to nearest: Well ----------- _---------•--.--------Foundation ---------------- Prod: ;Line ------------- -------- . rte - ---- REPAIR/ADDITION(Prev. Sanitation Permit# ------_-----_---- ------ ------- -- Date.._:---.----------------------- .) - Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------------------------- ------------------------------=---------------------------- a `:- ; ----------------------------- Disposal ---------- ------Disposal Field {Specify Requirements) ------------------- a------------------------------ -------------------------------------------------------------------------------------------------------------------- -- - ------------------------------------------ - ---------------------------- (Draw existing and required addition,on reverse side) 1 hereby certify that 1 have prepared this application and that the work i will be done n accordance-:with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Horne 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 Compensation laws of California." k Signed ----------------------- --- ---------- ------------------------ -------------------------- Owner ` ' Title CvT rc� BY �4= �- ---- ' (If other than own r�) �f FOR DEPARTMENT USE ONLY BUILAPPLICATION ACCEPTED DING PERM 7ISSUD-Y -- --------------- ------------------ ------------------------------ - ----- --------------------------DATE ----� ;/rte--:_� _ ADDITIONALCOMMENTS --------------------------------------------------------- ----------------------------- -------------------- ---------------------=--------------------------- -------------------- -------------------------------------------- --------------------------------- ------------�------------ ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- - -- - _ - ----W---- �y ---- r, Final Inspection by= /�-�' - ----------- --- ---------------- ------ -----Date ---- /S-_! --- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 '' 1='68 Rev. 54