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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - - Permit No. -- --- ----- ------------ ------ -------------- (Complete in Triplicate) --------- - -- J��---------------- This Permit Expires 1 Year From Date Issued Date Issued ----------------- _ _ ----- -- ------ -_------- Application is hereby made to the San Joaquin Local Health DiOr'ict'for a permit to construct and install the work herein described. This application is ma a in complian with C unty Ordinance No. sting RUIes and Regulations: .JOB ADDRESS/LOCATION I�itic� _��J,�Q�,.-._I .-`'"` -.CENSUS TRACT --------------A----------- Owner's Name -6--------- ' --------------Phone --------------------• -------------- Address .------- --------------------------------- ------------ City ----------------•-- Contractor s Name ------- �r~"-t-e� _ J" eide __License # __l. _3 "_ Phone --------------------- -------- installation will serve: Residence 2 Apartment House-EJ Commercial❑Trailer Court ;❑ IMotel ❑Other -------------------------------------------- Number of living units:_____1_F_._ Number of bedrooms ---�-___Garbage Grinder --- __._---- Lot Size _____--OL--__________ _ _ -------------- E 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 F-] Adobe.F 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.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK![e Size_A :2_ /------- _______________ Liquid Depth __V--___.___.--------_.--- Ca acit leap T � Material__ NO. Compartments �- P Y -- YP \ Distance to nearest: Well -------- _Q______ "______Foundation -`_._r ---___`_ Prop. Line _-___ -_.--__;___-__ [ ] No. of Lines --------�------------ Length,of each li.ne-----------`�_--------� Total Length :--------------------------- �T I � dt 'D' Box Type Filter Material-----:�_�.4---,Depth- Filter Material ---------J-9.............. ---------------- Distance to nearest: Well ___.__.__/_�Z>:__ _"Foundation _: "`f_�_!_=.'___ Property Line ___- ----------------- SEEPAGE PIT [ ] Depth -------------------- Diameter ----------------- Number _.___"_-I------------------ Rock Filled Yes ❑ No 0 Water Table Depth --------------------------------------->--------Rock Size ------------------------ ------- Distance to nearest: Well ----------------------------------------Foundation ----------- Prop. Line ----- -_------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------.------------------) Septic Tank (Specify Requirements) ---- ------------ ----------------------------------------- ----------------- --------.F---------------------------- Disposal Field (Specify Requirements) �----- -----`----------- /S / �f- J ------- ------------------------------------------------------------------------------ -------------------------------------------------- ------------------------------------------ - --------- -------- --- -------- ----------------------------------------------------- (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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." i Signed ----- ---------- Owner �h .10 -- Title ---` rl -t� ---------- ------------------------ ------------------------- - --- BY ------- ---------- - - - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-- -- _ - ------. DATE .1r_ -_"!�F-0-- - - -- ---------------------------------------------------------------- BUILDINGPERMIT ISSUED ---------------------------------- ---------------------------------------- -------------=--------------DATE -------------•----------------------------- ADDITIONALCOMMENTS ---------- ----------------------------------------------------------------------------------------------------------------------- --------------------------- ----- --------------------------------------------------------—-------------------------------------------------------------------------------------------------------------- - --------------- a - - - - - Final Inspection by: "r -------------------------- --------------- --- --- ---------------------Date/-, '"'.---�'` --- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6B Rev. 5M.