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FOR OFFICE USE, APPLICATION FOR SANITATION PERMIT ----------------- ------3; pm - 'L ------ (Complete in Triplicate) Permit No. -------------------------- ------------------------------- This Permit Expires I Year From bate Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit t described. This application is made in compliance with County Ordinance No. S49 a o construct and install the work herein JOB ADDRESS/LOCATION .._._-_ ) /' �� and existing Rules and Regulations: �� , ---- - ---------- s y r Owner' Name ( ( , y� i-�-/-�J i� -- .� �._ ------------------ --------CENSUS TRACT _.. - -/-------� -==Sc� i' =r Address � ------------ - - ------- - ------ w f`- --- ------,.-- � � �/�� ---- ---Phone -- Contractor's Na h ' i - -- ---- . _ ------------ ---------------- ------ Cit ------r �%� / Name -7 �� Y ( �� --- ------- il ------ -------------------------- u Installation will serve: - --•-----License # �� , Residence ��-- Phone ;�'/ :(/ 9' -artment House,❑ Commercial ❑Trailer Court Motel ' - ❑Other Number of living units------------- Number of bedrooms ---- Water Supply: Public System and name __ "-'----Garbage Grinder _-.__-_-_ pp Y: Lot Size ......................... = 4r — ( c ----- Character of soil to a depth of 3 feet: Sand' - - --- ------------•-•---- ----------Private ❑ Silt❑ CIaY .C) Peat � ._- --•-- - ❑ ,� Hardpan ❑ Adobe � ❑ Sandy Loam '�] Clay Loam:❑ M ❑ Fill Material/)/�J - --•- -_ If yes, type ----------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must NEW INSTALLATION- (No septic to or see a e in - • - _ be Placed on reverse side.) PACKAGE TREATMENTANK P g� pit permitted if public sewer is'available within 20D feet,) �/ Size------- /" kc r _ - �� l ------------- Liquid Depth _ate/ _.. Capacity _"1_ __� _. T e YP , - Material ----- Qistance to nearest: Well �� (` No• Compartments -21 LEACHING LINE Foundation _4 --�-- " prop. Line 1 j� No. of Lines - , _1_ ----• Length of each line.-- - - 'D' Box �_J-r " r _ Total Length �'�i� i Type Filter Material / .------Depth Filter Material "•-` ---Distance to.-nearest: Well. SEEPAGE PIT. z Foundation �! , -- _ Property Line 5---- ---•--- ' IP rtY �.._. p --------------, ,'--- -- Number --- ---- - Water Tabler� ----------------- Rock Filled yes ❑ No Depth . ------------- ---------- --------Rock Size Distance to nearest: Well _____:_-"__"_" ' ' "" Foundation REPAIR ADDITION(Preva Sanitation Permit# ______-_"_- " Prop. Line -----•-•--,--'--------k Septic Tank (Specify Re uirements ---------------------- Date -------••------_--"" I Y q --------- } h ---- ---- ----- ------------------- Disposal Field (Specify Requirements) ------------- -------- ----- ;i ----------------- L- ___________________ ___________________ ____________ - _ ____________________________________________________________________ __ ________•__------- __ (Draw existing and required addition on_ __reverse_ _ _ _sid__ e)__ 1 hereby certify that I have prepared this application ane! #hat the'workTwill &e-done in accordance with San J County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. f sed agents signature certifies the following: Joaquin.. "I certify that in the performance of the work for which this permit is issued, I `shall not employ r�ct. Home owner or liven-!'h 'y as to become subiect to Workman's Compensation laws of California." R y any person in such manner Signed ---------------- - BY Owner --------------- ----- ---- u :I! (If other than, weer) Title _. � ; X-7. FOR DEPARTMENT USE ONLY $ APPLICATION ACCEPTED BY -_-- --- F BUILDING PERMIT ISSUED ADDITIONAL COMMENTS ------------------ ! DATE ----------------------------DATE -- ------------------------------------------ ------------------------- - ----------•---------- - --------------------------------- ---------------------------- ------------ -- ----------------------------------------------------------------------- ----- -------------------------------- --------------- Final Inspection b --------------- ------------------------------------------------------------------- --------------- ------ _ - ----- - ------ -- - - � _"� ! ---- ----Date _--- - - - --- ----c�.--- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'6$ Rev. 5M 1