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FOROFFICEUSE. " f,. .--,.* APPLICATION FOR SANITATION PERMIT. 7_•5� POrmlt No. ? �, _ _- -•..................------ ................... (Complete in Triplicate) ... . .N...__;�.� .,�_ .. '--......_._..__.. ' This Penult Expires t Year from Dat • _M_ _.. � ................. ..................................... to Issued ..�.......:» 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 applicotion is made in compliance with Co my Ordinance No. 549 and existing Rules'and Regulations: JOB ADDRESS/t0 O .. ........ ..... ...................................CENSUS TRACT .......................... Owner's Name -. _.. /:�. ..............:...,..........._..... ..' ... ...........Ph e ._._ Address . City ... on_.._.... —,.---- Contractor's Name ... ie !... L•``` ...4��..Llcense # .1 ,! 3�' Phone .........................\� Installation will serve. Residence�partment House Commercial OTraUer Court �] Motel ❑Other ........... Number of living units:_._1....... Number of bedrooms ...... Garbage Grinder .........:.. Lot Size ............................................ Water Supply: Public System and name ---------------.........................................._-....................................................Private t Character of soil to a depth of 3 feet: Sand b Silt© Cloy 0 Peat❑ Sandy Loom 0 Clay.Loam Hardpan❑ Adobe 0 Fill Materlal ............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 I ] SEPTIC TANK I } Size. .. (> Y ............... Liquid Depth .�/................... - Capacity -1 Q- = _. Type 2 Material.. -sL--. No. 'Compartments 2................ Distance to nearest:`We --- ll .......fi r- --•---.... ...Foundation .......1.�'.. Prop. Line .. 1r�.... V' V LEACHING LINE [ �. No. of Lines ...... Length .of each l€ne........ ..... Length ..� -. .•- ' 'D' Box .�-�.:..... Type filter'Material ..........S._ -- r�__.Depth Filter Materia! ......... .. �� .............. .._ - ., �-� 7. Distance to nearest: Welt ....... .... _ .... Foundation ._._.��.. Property line -.-_. •--• SElCPAGI? PIT ( Depth ....-. Diameter ' , Number ........;Z-- . ... .-.. Rock Filled Yes (3 No 0 i Water-Table_DepthK:..:_. od oc , Y Size.-. . Distance to nearest: Well '"_----`b__ ._..._....R k Foundation ----I.a.. Prop Line ..... REPAIR/ADDITION(Prev. Sanitation Permit Date ______________________ v ' Septic Tank (Specify Requirements). _____________________________ ..... 1 Disposal Field (Specify Requirements) •--___ ..-••.......:............................ ..._...........,,----•-----•--------.........,.._...... -••---•---••...................................••-------.........--•----- ' l " , ---------------------- ---------------- ------------ ...... ....... •--------------------------------- ----------•----•••----•--••--•••----------------------------•-•---- ........__. i ,—.� (Draw existing and required addition on reverse side) 1 hereby certify that# have prepared this application and that the work will be done in aaerdance 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 ts issued, 1 shalt not employ any person in such m6aner E as to become subject to Workman's Compensation laws of California." Signed _-•-------- ----------- - -f-------- -. --- -------•----- Owner BY ----------- ------ ---- - - - Title ....... ....... -----._.............. (If other than owner) R DEPARTMENT USE ONLY } t APPLICATION ACCEPTS© BY ©ATE :b ` DATE -...-- .............. .. .:..... y ._ _ . G BUILDING PERMIT ISSUED ----- ------ --------- ----- -----------------•- ---- ....._.._._ ADDITIONALCOMMENTS ---------------------------------- •-------------:------•------••----•--------------•--------------_______-- ............. ....................... __,"------------ ------------------------------ ------- -..........-..-------------------------------------.---------..._.. ------_--.... ------ --.__--- __ .._, ... Final Inspection by.. --:Date .. ------ :' EH 13 24 1-68 Hev. 5M � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M