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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ Permit No. __7a-n01....... (Complete in Triplicate) ----------I------------------------------------------- Date issued 8_1_70...... ----------------------_--------------------------------- This Permit Expires 1 Year from Date Issued 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 ____ -Shell Station — Moreland & Hammer, Stockton --CENSUS TRACT _----------__----------- Owner's Name F- - - Const. -------------------Phone ___________________-___-_, - - r C ns - Address -----6040 San Juan ------------------------ City -- Citrus_.Heights, Calif Contractor's Name _ ------------- Certified- Sewer_ Inc-.-------------------------------------------License # _2541-73--___-____ Phone __466-3142---_----_-- v Installation will serve: Residence ❑Apartment House[] Commercial ❑Trailer Court ;❑ �- Motel P Other ------Ser-vlc0-_5tairian----- Number of living units_____________ Number of bedrooms ___________Garbage Grinder ------------ Lot Size _-__------___.__.____________________.... Water Supply: Public System and name ----------------------•-------------------------------------- --------------- %--------Private ❑ Character of soil to a depth of 3 feet: ,Sand'[] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan N 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,] PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size----------------------------------------------- Liquid Depth ----------- -------------- Capacity ---- ----- -------- Type -------------------- Material---------------------- No. Compartments ---------------------- 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 --------------------.-----------I-__..____-_ Distance to nearest: Well _______________________ Fouftdiation ------------------------ Property Line _________--_______._____ SEEPAGE PIT [ ] Depth ----_0----____ Diameter l _ ______ Number -----------I--------------- Rock Filled Yes 5 No i❑ Water Table Depth -- �-------------------------------------------Rock Size ---- ---------------------•--- ; Distance to nearest: Wel! ---------:�_IA_________________--Foundation ------ __-__ Prop. Line ---._____---____..__-. 1 REPAIR/ADDITION(Prev, Sanitation Permit# __------------------------------------------ Date ____.________________-___________) Septic Tank (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 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, 1 shall not employ any person in such manner as to become bj t to Work an's C� pensaflon laws of California." Signed ---------- Owner BY ---------------- - ------------------------------------------------------------- Title - ------------------------ ---- ---------------------------- (If other than owner) FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY --- - k�i` - __ DATE ---°34 Z_ 7i�•------------------- BUILDING PERMIT ISSUED ------------------------------------------------------ --------DATE ------------------------- - ADDITIONALCOMMENTS ------ --------------------------------------------------------------------- ---------------------------------------------------------------------------------- ,� ---------------------------------------------------------- ------------------------------- --------- --- ----- ------------------------ Final Inspection by: ---- ,�[-�_ l" ----------------------------------•------------------------------------------------ Date __ � 7L SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M