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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � -------------------------------------------------- Permit No:(Complete in Triplicate) _ ___________________________________________________ Date Issued _�_I This Permit Expires 1 Year From Date 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 w/jtfh County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -------- y _ ______ __ __ -CENSUS TRACT -------------------------- Owner's Name 4 - hone - Address - --------------- � ��J --------------------- City --------------------- or Contractor's Name .. ___. _ __ _-__ 't•`-_ ____ " _ ----------License #pZF—.C�.J__AX PhonezZ- Installation will serve: esidence Ap ment House,❑ Commercial :❑Trailer Court ',❑ Motel ❑Other ------------------------------------------ - r , Number of livingunits:____ _____ Number of bedrooms ._ _ ._.Garbo e Grinder ____ ____-__-__.--__- g Lot SizeQa_- -____ Water Supply: Public System and name ------ _ r __.___4va---------------------------------------------------Private ' ------- ------- Character of soil to a depth of 3 feet; Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam,* 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet, alr PACKAGE TREATMENT [ ] SEPTIC TANK Size - X��k/ ---_ Liquid Depth ___�_____�__-__.,...- �t Capacity1Jd1f6r�t'� Type Material---- — No. Compartments ---' `-------------- '�, �Q' —r Distance to nearest: Well -------�-------------------------Foundation -.--------------.___-- Prop. Line -------------:--____-- LEACHING LINE No, of Lines _____ ______________ Length of each line-------- ----.------ Total Length / ___-___________-_-__ D' Box ----- Type Filter Material _ -----.Depth Filter Material ----------- _________-_____-_____-_ el f Distance to nearest: Well ____�5'�____________ Foundation ___r_________________ Property Line __�___-__-__._____ ( f _ Rock Filled Yes (�; No C] } � Depth ___--�------------- Diameter e�_��_-- Number --------____-- Water Table Depth ---- Q-----------------------------------Rock Size ------c�_rr Distance to nearest: Well ----- --- ----------------------Foundation __15;!_r_______ Prop. Line ___ _ _r_._ REPAIR/ADDITION(Prev, Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ----------------------------- -------------------------------------------------------------------------------------- ---------------------------------------------------- - - -------------------------------------------- - ----- -------- -- ----------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin t County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health bistrict. 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 become subject to Workman's Compensation laws of California." Signed --------------------- --------------------- - Owner I BY ---------- --- ----------------- Title _.. ------------------------------------ a_w{If other than owner) 11 -- FOR(DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- --------------------------------------------------- DATE -_ ------------ BUILDINGPERMIT ISSUED ----------------- --------------------------------------- -----------------------------------------------DATE --- ------------------------------------- ADDITIONAL COMMENTS - - ------------------------------------------------------ -------------------------------------------------------------------- - - --------------------- ------ --- ----------- FinalInspection b ------------------ --------------------------------------------------------------------- ------.Date ---'-- - 7 -----------------1 SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M