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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------- --- ---------------------------------------- - Triplicate) ;Complete in Triplicate ...........---------- ------------------------------- Date issued ---- �__�-�« 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 madeiin compliance with County Ordinance No. 549 and existing Rules and Regulations: - -------------- - ------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION .-_.-----rte!-11777 --�---- g-- - ------ Owner's Name Cy l! �� ' -. ---Phone,-, -�-- y n _ Cit � N/ _.' - -------------------------•-----••----•-•---- j Address S`k--��-------1 �l�-[ ---- = Y �° License # _.� i -..- Phone ,)-._Y -r� ------ f Contractor's Name - r. Installation will serve: Residence r6Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑Other --------- ------------------- -------------- Number of living units:------ -.-- Number of bedrooms ----5----Garbage Grinder ------------ Lot Size -------------------------------------------- Private ito Water Supply: Public System and name =---------------- Character of soil to a depth'b` fe Sand'fg Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam El ' "' 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.) I NEW INSTALLATION: {No septic;.tank or seepa/eerritted if public sewer is available within 200 feet,) ` --- Liquid Depth -------------------------- , ---------------------- - PACKAGE TREATMENT [ ] SEPTIC TANK [ ] ize----------------------------------------- - q P - Capacit Type Material - No. Compartments InY --------------- Y00 Distance to nearest: W ----------------------Foundation ---_------__-_-_---- Prop. Line -_-----._--_.:..--_.__LEACHING LINE [ ] No. of Lines _---------------- of each line-------_-------------------- Total Length _---._---.._-.-_-..--.-_-- 'D' Box --'�-------- Type Fill --------------------Depth Filter Material --------------------•---------•• Distance to nearest: W�Ic 11 - ---------------------- Foundation --_--------------------- Property Line. ---------•--------•=-- i SEEPAGE PIT [ ] Depth --- _ __-.-- meter -- Number --- ------------------------ Rock Filled Yes ❑ No i❑ TableWater Depth -- -- ------------ -----------------------Rock Size ------ --------------•--------- Distance - ------ Dstance to __Foundation --------------------- Pro Line __----_------------ � nearest: Well ------------- ------------------- P• REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------•------) Septic Tank (Specify Requirements) - ---_ ---------------------------`-- --- � I Disposal Field (Specify Requirem ts) - 11 r-? � --- ----- �j�u�---�/� --- 5�� T ------------------ -- ------------ - ---- - ----- ' `1 (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: "1 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 Work n's Compensation laws of California." Signed _ Owner -- ----- ------ ---------- -- ---------------------------------6 v�_4- By L - 7 -- ------ ------- Title ------------------------ - --------------------------------------------- {If other than owner) 1 FOR DEPARTMENT USE ONLY ( APPLICATION ACCEPTED BY ---- ---------------- DATE -..--_-~- -'- - ----- BUILDING PERMIT ISSUED ---__ _-- - ----------DATE -----------•-----------•------------------ ADDITIONAL COMMENTS ---------- --------------------------------------------- ------- ---------------------------------------------'---------------------------------- ---------------------------------- - - - _---------------- ,��_s} ---------------------------------- -- - -- ------- -- - -- Final Inspection by: -- Date __-- --'-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M