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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit7o 6 �Ok (Complete in Triplicate} q i T,,. Date Issued - --"-------�-.::a , _------_---- ------a_--_---_---_-- his Permit Expires 1 Year From Date Issued -r F 1 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/LO TION . :..-- -7------------------------------ ------CENSUS TRACT --------------- Owner's Name ` `--------- -- -(A-A- I-- -' _:.:..:.. ------------------- I Phone r ; /� -- _ I -- c� o ---- Ci Address -------------� I--- ��- ._. -- -- - ----- -- --=-- - - :7-p a ��Zhone Contractor's Name ' , t License # __ Installation will serve: ResidenceILLAartment House❑ Commercial ❑Trailer Court 0- Motel ❑Other ---------------- ' Number of living units:______.._ Number a dr oms -- __�G ba Grinder/4-40---- Lot Size r - - - a-••------- Supply: Public System and name t.. --------• . --•----•--------- ----- Water --w= Private ❑ Character of soil to a depth of 3 feet: '; Sand'❑ Si ❑ Clay Peat❑ Sandy Loam.: HCl y Loam. Hardpan❑' ' Adobe' EilI Material __.___.._If-yes,type ... ------- ----------------- plan, showing size of lot, location of system in relation to wells, buildings,_etc.._mvst-be_placedzon reverse side.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �y PACKAGE TREATMENT SEPTIC TANK T I Size { F x� { ] � ---------•-------------------------•------------ Liquid Depth _...--------------........ I I ` Capacity ----- -------------- Type ------------1------- Material.:'------------------- No. Compartments ------ ----_-------- Distance to nearest: Well yf` • . . "-Foundation __..._-.r__.__i ._.. Prop.11ne _...._... LEACHING LINE [ J No. of Lines --------------------- Length o�edc line---------------------------- Total Length �T 'D' Box ________:_ Type Filter Mafierialf-i`____ __________Depth Filter Material z............I----------.------------_------ Distance to nearest: Well -------_----------------- Foundation . ---------------_------ Property Line. ___....._.______--.:.--- (, SEEPAGE PIT [ ) Depth -------------------- Diam�er.. ---•------------ Number ---- `=-------------- =---Yitock :Filled Yes {] No i0 .� Water Table Depth- ------------------------------------------.......Rock Size ----------------------------- Distance _...-----=---•---------• --•Distance to nearest: Well -----1----••-------------------........Foundation ------ Prop. Line _...---.......------- I REPAIR/ADDITION(Prev. Sanitation Permit# _.._._-..---- - ---- Date _______ ----------------- ,• Septic Tank (Specify Requirements) ----m-------•--------------. _.__ - .. -- ------------- Disposal Field (Specify R-ega�rir_ements) --------- --� ------------------------ ---- - --------- fl- -- - ----------------------------- ------- � = ( i (Draw existing and required addition on reverse side) i ,k I hereby certify,that I have prepared this application and that the work will be done in accordance with SonJoaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Wealth District. Home owner or liven- 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." r Signed ------------------------ --- g ------------ Owner t r (/(J ' By -------------------- - ---- - ------------. Title -- If of r t n owner) /`` TMENT USE ONLY APPLICATION ACCEPTED BY ---------- ------------------------------- DATE _- `=,�- t.�rC ------... BUILDING PERMIT ISSUED ----------- - ---- -- -- DATEt-----•-•------•-•-------•-------------- I ADDITIONAL COMMENTS ---------- ----- ---- •- -- `-- ------...... �F j a ---------------------------•--- ------------------ ----- -------•• - --------•---------•j . --------•---------------•----------•---------------------------------------- ------------------------------ l ------------- - --- ---- - ------- -------------------------•------------------------------------------------------------ ----•-----------I------------- ' ---------- ------------ - -- - ------- ------------I-------- ---------------------------------------------------------- ------------------- -•---------•--._.-..... FinalInspection by-- ------- ------ ------------------------------------ ------------------ --------------------Date -_. ----••------•------- 1 JOAQUIN LOCAL HEALTH DISTRICT (/1� E. H. 9 1-'68