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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT u ' �� 99t _ _ Permit No. --------------------- - -- ------- -------- -- -------------------------- {Complete in Triplicate) ---- /—/S -- Date Issued - __.____~_.. ---- This Permit Expires 1 Year From 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. 549 and existing JRules and Regulations: I (OB ADDRESS/LOCATION -s F.. PWZ ?d"1. ,. Fxz.• 9AW---CENSUS TRACT ------- -----=-- Owner's Name -- ---. - * _.fir-- -------------------------------- Phone 'a�_/ ddress _ /-- ?V IOA--- ---- -------------- City /�1�✓ .' Contractor's Name ----- ----.0 le------- ----------------- -------License # ---------:----------- -- Phone ------ --------- ------------- installation will serve: Residence [ rApartment House°❑ Commercial :❑Trailer Court i❑ 4 Motel ❑Other -------------------------------------------- I' Number of living units:---,/--.--.- Number of bedrooms Y----___Garbage Grinder r Lot 5'sze -___Water Supply: Public System and name ------------- ------ ----------------- ------------------- ------------Private `Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay,❑ Peat ❑ Sandy loam lay Loam E] Hardpan ❑ Adobe ❑ Fill Material --AID_._ If yes, type::'-_----------------------- t {Plot plan, showing size of lot, location of ,system in-relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: fNo septic tank or seepage it permitted if public sewer.is available.within 200 feet,) ti 3\ r pP p -.��..� I PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------------------------- - Liquid"'Depth -------------------------- CapacitY ., = Type -------------------- Material--------- ------------ No. Compartments ----------- ---_------ _`Foundation ------------- --- Pro Line ---------------------- I --------------------- 1 Distance to nearest: Wel! _________________________________ ------ p• LEACHINGILINE [ ] No. of Lines ------------------------ Length of each line---------------------- Total Length ,----------•-----------•---- 'D' Box ---------- Type Filter Material ____________________Depth Filter Material --------------------.-------------------•--- Distance to nearest. Well ________________________ Foundation __-_.--_-___ -- ------- Property Line ----_-___---_____------ SEEPAGE PIT [ ] Depth --I----------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 WaterTable Depth -------------------------------- ------- -------Rock Size ------------------------- ----- $ €t Distance,to nearest: Well --------------------------------------- Foundation -------------------- Prop. Line --------------..-.-.-- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- i t � Septic Tank (Specify Requirements) -------- ----------------- 0----------------- --------- i ;! '.` ------ Disposal Field (,5pecify Requi emen#s) " ` = 1�C — -d ----- ------------------=------------ --' Vic'~'- - ---- ---- _.._. - �. = - —..— - --------- ----------- 4 (Draw existing and required addition on reverse side) j I 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,.t shall not employ any person in such manner as to become subject to Workman's Compensation laws of ealifornia." Signed - ---------- ------- --------- ---- C__ Owner --------------------- BY - `I _ .- itle .- - (If other than owner) - FOREPARTMENT USE ONLY v 1, I + -------------------------------- ----------------------------- DATE -_.._ l APPLICATION ACCEPTED BY ----.__�T BUILDING PERMIT ISSUED ------- -- ---------- --------=-----DATE --- --- --------------=- - ADDITIONALCOMMENTS - - ----- -- -- -------- ------- J ---------- --------------------- ------------ ''-----•------- ,-----•--- i ------------- - -= ` - ----------------- - - --- i ----- --------- --- ----------------------------- _ --- ------- ----------- ---------------- -- --- - ff Final Inspection ------------- ------------ ----- -----.Date ---------------------------------------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'6$ Rev. 5M