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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I ---lftt�- - ------------------- ��] ---------- Permit No. // (Complete in Triplicate) I/j�/�/-------------- •� 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION .-__-/ ------ -r___C/.!I ------------- -------------------------------CENSUS TRACT -------------------------- Owner's Name /V' f------1 j--- -rf � Phone Address ------------ City ------- -- - Contractor's Name ------ ---- - ------ del_- _-_- (.c��---„ _License # _./�_/t y _ Phone Installation will serve: Residencelo,(partment House'E] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------- Number of living units:----- Number of be ooms -3--------- 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 ❑ Adobe ill Materia) ,w'i't__._ If yes,type _______________ (Plot plan, showing size of lot, location of systemmin_elati n+” to wells, buildings, etc. must be placed on reverse side.) NEW,INSTALLATION: (No septic tank or seepage.pit.perm Meg',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 __________ ____________ AD_ '.Foundation _ _Dpp. Line ---.______________..._ _ LEACHING LINE ] No. of Lines ________________________ Lea h of each line__: -------------� Len tth 'D' Box -_-- --. -- Typ"""e"�i! eater al""'""7"�`�"_7"`_�ept Filter Matea.f bistance #o nearest: Well ------------------------ Foundation --____- �roperty�Line _--_---------------_---- SEEP,IkGE PIT [ ] Depth ------ ------------ Diameter ______-_______ Number .___ ....._ --____ Roe Filled Yes ❑ No Water Table-Depth*----------------------------------------------Rock ------------------------------ Disfiance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------:.--.---.- t � REPAIR/ADDITION(P ev. SanAtr nn Permit# -------------------------------------------- Date __- -----------------------------_I Septic Tank (Spec Require�nenks ___ - - f� � � -------- ----------------------------------- ---------------------------------- Disposal Field {Specs#y:,Requireme%5}�k _� .�y. /! - - -- --=----- ---r-.�__ _�_�__- _-. ---1----------------------- ------------------------------- (Draw - -,- ------ ----------------------------- ~---------------------------- ---------------------------'--- - - [Drawexisting and requited addition on reverse side] I hereby certify that I have prepared this application and trliat the work�*ill be e�one in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations� f the San Joagdih Localf,Health District. Home owner or,1 cen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issuedr-�I-shall-not employ any person in such manner as to,become to W an's Compensation laws of California." Signed _ �� Owner •f - - Title ---- BY --- ------ - G.� " '.�� - --------- - - -- - - --- - - (If other than o er) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ------ -------------- ---------------------------------------------------- DATE -- 1=E BUILDING PERMIT ISSUED.._-_. DATE ------------------------------------------- ADDITIONAL COMMENT9.3- ----- - -- ----- - _ _ __ �. -------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- -------- - --------------------------------------------------------------------------------- ---- -- ---------------- Final Inspection ---------------------------------- ns ection b i '= Date ___. l__ __--'.-________ --------------------- ---------- ---------------------------------------------------------------------------- Final ---- --- -- - --- ------ 901 PY - --- - ------------------------------------- ------- SAN;JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �' —