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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 Application is hereby made tot San aquin 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 Z-__---�-- _Il �d� ¢----- -------- -------------- .. -y -. .__CENSUS TRACT ---- Owner's Name ---Me—-----1-1?-------:S�t�-_e__ -� ----fes_!S:-------------------------------------- ----------------- Phone _IMJ3__207- Address ----t a-&Z . 3. ---�..1, ----- /�6r -------------- City J _?� _l e ------------------------------------------ Contractor's Name r---I / License #�-1f_- �-___- Phone 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 ❑ w Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam jA Clay Loam R - x 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 seeps a pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK' Size_-________._____ [ ) [ ] --------------------------- - Liquid Depth -------------------------- � Capacity --------------------- Type --- ---------------- Material------- ---- N Compartments -----------------_ . 0 Distance to nearest: Wel ------------------------------------ ---------I----------- Prop. Line -----------------...-- LEACHING LINE [ ] No. of Lines ------------------ ----- Length of each line---------------------------- Total Length ---------------.---.--__---- 'D' Box ------------ Type Fil r Material --------------------Depth Filter Mat rial -------------------- ----------------------- Distance to nearest: Well ________________________ Foundation ----------- -- _ Property Line __________________---___ SEEPAGE PIT [ ] Depth ___________________ Dia eter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------------ ----------------- Distance to nearest: Well - ----------------------------------Foundation -------- I -------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# __________ ________________________________ Date -------------- --- __________) SepticTank (Specify Requirements)-- --------------- -----------------------------------------------------------------•-------------------- - -------- --------------- Disposal Disposal Field (Sae ify equirements) ----/,07-0¢_____�1l 2_✓�----- __- ------------------------------------ I - (Draw existing and required addition on reverse side) II 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 become subject to Workman's Compensation laws of California." Signed ---- ------ --- --------- - -------- -----------------It- - Owner By .---- ~ Title ---------------- ---------- -- ----------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----`rt ----------------------------- -- DATE ------ ------- BUILDING PERMIT ISSUED ------------------------ ---------------------------------------------------------------- ------- ------DATE ------------------------------------------- ADDITIONAL COMMENTS .________. _____ ---- ---------------------------------------------- ---------- -- -------------------- --- ---- - --- -- --------------------------------------------------------------------------------------------- �Y ------- -- -------------- --- ------- ------------------- - ------------------- --------------------------------=------ ------- ------------ -- ----- ________________________ -------_---__---- __ _____ _ __ ___ _ _ _____ __ _____ _____ _ _ __ _ _ _________________________________________________ _.. Final Inspection y- -------------- -------- - ----- -----.Date ------ ------- ----- -/_- ------ SAN JOAQUIN LOCAL HEALTH` DISTRICT ,t E. H. 9 1-'68 Rev. SM