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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- _ p p - "l (Complete in Triplicate) Permit No. f Date Issued t�-.J ------ -.'-2 This Permit Expires res 1 Year From Date Issued f 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. 54 and existing Rules and Regulations: JOB ADDRESS/LOCATION -- --------- ------CENSUS TRACT -------------- ----------- Owner's Name -- ---- - - ----------------------------------e -----Phone ------------------------ ---------•- Address - . ---------------------------------------- - - � - __ CItY - -=---------- -= i Contractor's Name ------------ - -�._ --�----- ----- --.License #/II _ Phone -------------- ------•--•----- Installation.will rserve: Resid_ence A artment House❑ Commercial❑Trailer Court 1❑ __ W Motel ❑ Other -------------------------------------------- Number of living units:------._.__ Number of bedrooms s3__----Garbage Grinder Loft Size ----------------------------------------- Water Supply: Public System and name ----------------------•----------•-------------------------------------------------i'_'- Private Character of soil to a depth of 3 feet: Sand' Silt❑Clay ❑ Peat ❑ Sandy Loan�- 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.) p seep a .pili permit#edFif public sewer is availablelwithin 200 feet,) NEW INSTALLATION: [Na septic tank or �+ ' ire f r I PACKAGE TREATMENT { ] SEPTIC TANK[ ------------- Liquid Depth --7---------------------------- o,` Capacity _ _ ; Type _---------------- Material_�„--- No. Compartments ---_•-----_-- x � istance to near : Well ---� ______ '-- -----------Foundation -------I 0_1------ Prop. Line --- -------------- e LEACHING LINE [ No. of LineJs _�_.__ _"-___ Length of ,each line-40---------------- Total LengthI_� �'� D' Box _.'----- Type Filter Material --------- -----'--.Depth Filter Material ---- ----------------- r Distance to nearest: Well -----!� 15----------- Foundation ------------ Property Line ____S ______________ SEEPAGE PIT [ ] Depth ---------- Diameter ---------------- Number ----------------------- ---- Rock Filled Yes ❑ No .id Water Table!Depth ----------y------------------------- -----------Rock Size -------------------------------- I Distance to nearest Well `--------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date -----------------------------•----) SepticTank (Specify Requirements) ------------------------- -------------------------------------------------------- ------------------------...-,:.--------------------------- Disposal Field {Specify Requirements) ----------- --------------------------------------------------------------------------------- -------------- -------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------- (Draw ---------------------------------------------------------- (Draw existing and required addition on reverse side) ` I hereby certify that 1 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^' the performance o the work for which this permit is issued, I shall not employ any person in such manner as to become su act to Workma 's ompensation laws of California." Signed Owner - ------ j Title --�..(�-- i BY ---------------------------------------- (if other than owner) FOR DEPARTMENT USE ONLY [ APPLICATION ACCEPTED BY ------ .- - - - - - - --- - ------------------------ -------------------------- DATE -.1 c3 " D BUILDING PERMIT ISSUED ------- ----------------------- -------------------------DATE -------" ---------------------------------- jADDITIONAL COMMENTS -------------------------"-------------------------------------------------------------------------------------------------------- -------------------,------ --- --------------------------- ------------------------------------------------------------------------------------ ------------ _ , -- -----+- -----=------- - -- } Final Inspection by: --- ------------------------------------------Dat . fz__' 1? SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.