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FOR OFFICE USE: 3 APPLICATION FOR SANITATION PERMIT ", ---------------------- Permit No:/4?fn_- ---` ,J (Complete in Triplicate) 7 ------------------------- -----------------1)-`--------- ' Date issued ----------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Jon Loca ' Dis �quilHealth trict 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: �=------ -----------------------------CENSUS TRACT JOB ADDRESSAOCATION r_----- --- ---- --- Owner's Name ---� �� ------------------ - 1--------------------- ---------- --------Phone ------------------- ---- Address , - � --------- ----. City !lr� _ _License Al - Contractor's Named- P �- - ------------ � - Phone `s~=• ''f t Installation will serve: Residence partment.HousetE] Commercial ❑Trailer`Court Moll ❑Others'W ------------- ------ J i v Q- Number of living units:-------- Number of,-6edr ores __ Qarbage Grinder . ___-_ tot Size,__- _ -�- ---7-- ------ 5 lie__ `___ Water Supply: Public System andrnam'e --_-- -•--1�✓ --- --------------------------------------------------------Private ❑ ---- Character of soil to a depth of 3 feet:� ' Sand'❑ Silt❑ Clay ❑.r Peat❑ Sandy,Loam ❑ Clay Loam .M Hardpan ❑ AdobeA Fill Material -- 0- 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 700 feet,) PACKAGE TREATMENT I ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------.,----- Capacity -------------------- Type -------------------- Material-------------------- No. Compartments --- --•--------------- Distance to nearest: Well -------'---------------------------Foundation ---------------------- Prop, Line ---------------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of eaeh line--------------------}------ Total Length ----------------•------------ 'D' Box ------------ Type Filter Material -------------'-------Depth Filter ,Material --------------------•------------------•-•-- Distance to nearest: Well---------____-------__---- Foundation ------------------------- Property Line ------------------------ SEEPAGE PIT [ ) Depth V - ------------ ------ Diameter - -------- _---- Number ------------------'----__-._ hock Filled Yes ❑ No C]Water Table Depth ------------------------------------------------Rock Size ---------------------------- Distance to nearest: Well ________________________________________Foundation ------------------- Prop. Line -___________-----_ t' REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ---------------------------------) ---- --- ------ Septic Tank {Specify Requirements) ------------------- a -------------------------- = Disposal field (Specify Requirements) ------------ / �� _ _.- .. �_ � 3 ' ----------------------------------------------------------[----------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that 1 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 issuedr I shall not Employ any person,in such manner as to become subject to Workman's Compensation laws of California.' I Signed --- ---� -------------------------------------------------------- - ;------------ - ----------------------- Owner 1 BYi +, Title i -'� - 1 of r han owner) f:OR .DEPARTMENT USE ONLY APPLICATION ACCEPTED 'BY ------4-----------` — ------- ----- --- ------ ----- DATE ------ -- -- ------------------------ BUILDING PERMIT ISSUED ----------------------------------------------I------ ------DATE ---------- ----------------------------- ADDITIONAL COMMENTS --- ------- --------------------------------------------------- -------- - ---------- - ----------------i----------------- --------------------------------------- --- Final Inspection b �-------------------------------------------------------------- - - -- �- -- - �- -- ---=------- py: ------- - ----- _--------------------------- - --_ --------.Date - SAN JOAQUIN LOCAL HEALTH DISTRICT R E. H. 9 ]-'68 Rev. 5M G