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FOR OFFICE USE: -. ; APPLICATION FOR SANITATION PERMIT ------------------------ ------------ (Complete in Triplicate) Permit No: ----------------------------------- ---------------------- This Permit Expires 1 Year From Date Issued Date Issued _J 7_-in0 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 mi34e in compliance with County Ordinance No. 549 and existing Ryles and Regulations: � M19 JOB ADDRESS/LOCA'LOCAT ON a____ --- ------ �crfs ..- `�--�,.5,. � C S TRACT ........: ...........-.. Owner's Name -- --- I----- ....... -)�------------ 1-�-------------------------- - ----- a3----- z-- -- '' 77 -----Phone .-�- --- ' � � l�-�__ Address ______._.___ _ Cite e?. Al,._ }�'r` -------- -----�---------- y / ----------------------------- ---------------- ------ _l Contractor's Name ____ ___ - f _�__ ___.___�_ �_/_IC'___._�. �1 ___.License# __----- 4- hone t Installation will serve: Residence ❑ Apartment House❑ Commercial Motel Pt6ther _.C"68 W'A_5--t I--`----- r Number of living units:------------ Number of bedrooms ____________Garbage Grinder Lot Size _- l�C?____---__._`A` Water Supply: Public System and name -___ _____ _ _ �_� ._ `_..___Cl__1 _`�___ ----------------------------------------Private ❑ _ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Material Ar.0_'_._ If yes,type ___________________________ (Plot iplan,r shown g"size of-lot,location of system iri,relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: '(No septic fan or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size------------------------------------------------ Liquid Depth -_-_______-___-__.___-_.- i Capacity ----- Type Material No. Compartments ! 8 Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- 1�'\} LEACHING LINE [ ] ."No. of Lines _____________ ---------- Length of each line.--------------------------- Total Length ______-_.________________ D' Box ----------- Type Filter Material -------------------.Depth Filter Material -------------------------------------------- j Distance to ge.arest: Well _____________________ Foundation Property Line. ------------_---------- SEEPAGE PIT [ j Depth ---VP___.____ Diameter ______________ Number ---------------------- Rock Filled Yes 9��No 0 ater'Table,,Depth --- --------------------------------------------Rock Size ------ ---- -------- --- !_/_6�istance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION --------._--_.__ .- REPAIR/ADDITION(Preva Sanitation Permit# --1----------------------------------------- Date ----------------------------------I ISeptic Tank (Specify Requirements) --------------7----- --------{--------------------------------------------------------------------------------.----------------------------- E Disposal Field (Specify Requirements) _ ________________________________ ------------------ ------------------- - - ------------------ ------,-----=------- - --- ---------------------------------------------------------------------------- -------- -------- *' (Draw existing and required addition on reverse side) k 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, I shall not employ any person in such manner as to be om subject to Workman' om nation laws o California." T <• Signed - - -- - - -------- -- --'-�-- - -- ---- ----------- Owner , BY ---- ---- - --- ----- ------ Title ...... --==---- ---- (If other than own FOR DEPARTMENT USE ONLY' APPLICATION ACCEPTED BY _______________ -------------------------- ------------------------ DATE --- = �. ---------------------------- -PERMIT ISSUED --------------------------------------------------------------------- -- DATE -----•-------� --------- --------- ADDITIONALCOMMENTS - -- ----- ----------------------------------------------------= ---------------------------------------- ---------------- ------ ---------------- ----------------- - - ---------------- ------------------------------------- ------ -- ---- ------------------ --- --------- --- ------ --�----------------------------------------- ----- Final Inspectao Date -------- '" ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M