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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- Permit No. ------ ------------------- ------------------------ (Complete in Triplicate) ------------------------------------- p Date Issued �=,aZ-3` This Permit Expires 1 Year From Date Issued ---------- --------------------------------- ---------- - 3-o r m 3 } Application is hereby made to the San Joaquin Local Health District for a permit to construct a installthe work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: + JOB ADDRESS/LOCATION . �� '''`' ,"e' � ------ '` ------CENSUS TRACT -------------- Owner's Name <�^- --- �__n ---� - ------------------.Phone ------------------ ------- ----- `� City vt -------------------------- ------------•-- Address ------ = °�' •' --------------------------------------------------------- pito Contractor's Name �� r�c� 'zr / l --.License # Phone g r� Installation will serve: Residence Apartment House,F Commercial❑Trailer Court ;❑ Motel ❑Other ---------------------- --------------------- Number of living units:----E------ Number of bedrooms _r-___---Garbage Grinder ------------ Lot Size s'i"'----------------------- Water Supply: Public System and name ----------------------- ----------------------------------------------------------------Private P r Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ] Clay Loam_❑ W Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- (Plot ___--_--.-- ------(Plot 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,) PACKAGE TREATMENT [ I SEPTIC TANK; f Size-.__ -T --------------------------- Liquid Depth -- --------•---------- Capacity toe, Material_4 - No. Compartments ------------ TYPe ----=-- -------- .......... Distance to nearest: Well ------S-70------------------------Foundation J.0--------------- Prop. Line .--------------------- LEACHING LINE [ ] No. of Lines ____ —---------------- Length off/ each line-----0a---------------- Total Length -/6-c7 --------------- 'D' Box _ _ Type f=ilter Material A---k..........Depth Filter Material ___ ------------------ ------------ -+ ----.• �{ Distance to nearest: Well --------ra�-______ Foundation __/_0�_-----------__ Property P tY Line. ------T--= 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 _____--.______--------------------) Septic Tank (Specify Requirements) --------------------------- ------------------------------------------------------------•------------------------------- Disposal Field (Specify Requirements) --- --------- ------------------------------------------------------------------------ -------------------------------------------------------------------------------------- . _ s (Draw existing and required addition on reverse side), I hereby certify that I have prepared this application and that the work will be donee 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 as to becomes le t�___Or n's Compensation laws of California." Signed ' •--- ------------------------------------- -- Owner By ----------- Title ------------------ ---------------- ------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY -- ---- ------------. DATE �- ---------- --- -------------------------------------------------- -- BUILDING PERMIT ISSUED ----------------------- ------------ ------------DATE ------------------------ *-- ADDITIONAL COMMENTS ---------------------------- ----- -------------------------------------------------------- r ----------------------------------------------------------------------------------------------- --------- ------------------------ - ------------------------------------------------------------------------------------------------------------------ ---------- --------------- --------------- - -- -- - Final Inspection by �/,� SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M T