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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _iA ------------- ---------------- - � " (Complete in Triplicate) Permit o_ ______3 -__ _ _S__ -------------------------=-------------- 3 73 } Date Issued ----------------------------------------- ---------- This Permit Expires 1 Year From Date Issued I 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_._71602-___ _____� ____w__ i {V_ .----CENSUS TRACT ----- Owner's ---- caner' N 2 f ,6 � )-- v-�� ---------- - --------------- Phone ' O s Name (/----- _ Address ---- .5, 1/- 1 _ ,/z<' C� City �iGrlfi�cirl.. -• ,,/ Contractor's Name --- _.__�—__._____ _� �_-_!/-______________._.______.License y91 --.____ Phone _ -------- Installation Installation will serve- Residence Apartment House'❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------------------ Number of living units:_.-----!_ Number of bedrooms _3___.Garbage Grinder ___________ Lot Size --------- Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam;❑ Hardpan [].,:. :;,Adobe.-E] 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 sepiic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size--------------------------------- ------------ Liquid Depth -------------------------- Capacity -------------------- Type -------------------- Material-------------- ------- No. Compartments Distance to nearest: Well ___________(cif ___________________Found ion ---------------------- Prop. Line ................ LEACHING LINE [ ] No. of Lines --- Len each line______ - Total Length ...................... D' Box ____---_-_-- Type Filter M erial ____________________D th Filter Material --------------------.------------.---•-•---- Distance to nearest: Well ___ _____________________Founds on ___._.___.______________ Property Line ---------....____,___.__ SEEPAGE PIT [ ] Depth �__________________ Dia ter ________________ Nu er .____.______________.__-,Rock Filled Yes ❑ No i❑ E Water Table Depth ---------------------------- --- ------Rock Size ---------------------=---------- a Distance to nearest: W II -----------------------------•---------Foundation . `,..-:__--.---- Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ -- __i__:_.______} . i Septic Tank (Specify Requirements) -- ---------------------------------------- ----------------------- `-------------------------------------•----------------------------- 1 Field 1 Dispo�sarY� (Specify Requirements) > --------- ? li'�---c'Z I ♦l v --------- ! _ l � --------------- -- ---- - T (Drowexisting 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 in the performance of the work for which this permit is issued, I shall not employ any person in such manner I' as to become subject to Workmen's Compensation laws of California." I � Signed Owner BY Title ------ --------------------- ----------------- - -------------- ------------------------ - - (If other than owner) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- �[_>�-_��'- -------------------------------------------=------------------------------ DATE ---- BUILDING PERMIT ISSUED --------=------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS - ---- ---- ------- ------------------------ -------------• ------ ----- --- ----------------------------------------------------------------------------------------------------- ---------------------- - --------- --- - 3 Final Inspection by ---- ----- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ""3