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FOR OFFICE USE: s. APPLICATION FOR SANITATION PERMIT �7 Permit -------------------------------- --------------------- (Complete in Triplicate) --------------------------------------------- Date Issued ----�----- __ This Permit Expires 1 Year From Date Issued an Joaquin Local Health District for a permit to construct and install the Application is hereby made to the Swork her n ( ` C ty.,Ordiiante No. 549 and existing Rules and Regulations: described. This applicatio is ade in compliance with Coun c b s/d -2----- - --CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION _4_ --- ----------- ` US -- Phone -g- ------------------------- --------- = r� Owner's Name _ Address -----. city M 1 -------- ---------------------- Contractor's Name ---_�I -------- �� = License .V391 X--- Phone Zl r�- - installation will serve: Residence Apartment House�❑ Commercial'❑Trailer Court i❑ MotelF1 Other ------------- --------------------------- Number of living units ---- Number of bedrooms ___/-------Garbage Grinder ---- --__. Lot Size -------- ---- Water Supply: Public System an name ----------------------------------------- -- -- - ------- - - ----------- '0 Silt El ❑ Peat ❑ Sandy Loam Private 19Clay Loam C1 Character of sail to a depth of 3 feet: Sand t aterial y e ---------------------------- — N Hardpan F1 Adobe ❑ Fill Ml - -- If es,type (Plot plan, showing size of lot, location of system in relation tgwells, buildings, etc. must -be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit perrritiecl if public sewer is availab) within 200 feet,} �1 ` ---Size---- --------------------------------- ------ -- Liquid Depth ------------------ 'PACKAGE TREATMENT [ ] .SEPTIC.TANK [ ]------size Capacity Type Y Material o. Compartments I l� p y '- -------- - I Foundation -- -- -- -------- Prop. Line ---------------------- r , Distance to nearest: Well -------------------- No. of Lines --------------------- -- Length of each line--------------------- - -- Tota Length -------- LEACHINGkLINE, [ } , Depth Filter aterial --------------------- 'D' Box ------------ Type Filter Material - --- -------- - p " a : __ Foundation ------------- -- - ----- Property Line. ------------------------ Distance to nearest:..W- ------------------ -- - Diameter ------- ------- Number .-------------- Rock Filled Yes '❑ No ;❑ SEEPAGE P,IT)..,[..,],. --Depth- - - -,-�:-� t�- . t I..-_»:-,^..,a'.�Wafer'Table,Depth --------- -------------- - Rock 5iie - ------------ --------- Distance to nearest. Well -------------- ------------------------Foundati -------------------- Prop. Line ----------•----------- 1 %1. Date ------------------- -------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------ ` _�ys_�e�lf--------- �-1----- - - - ----- - -.-..�� { --------- Septic Tank (Specify Requirements) ------------ -- Disposal Field (Specify,Requirements] - h } - # ----------•-----------------•------------- ----------------------- ----- -- -- � (Draw existing and required addition an reverse side) 1 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 Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: ` "1 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 Workm 's Compensation laws of California." � Owner 4 Signed ---- ---=----- - ------ ---------------- --------------------- -- -- --------- ------------------------- BY r ---------- Title --------------- -- - -------------------- --- ----------------- I - (If other than owner) i FOR .DEPARTMENT USE ONLY /p —�; DATE --- f/.�-I`.7��..----- ---- ► APPLICATION ACCEP D BY ----T1-8--0------------------------------------------------------------- PERMIT ISSUED ------------------ -----•-------------------------------- ---DATE ADDITIONAL COMMENTS --- t -------- - -- --- ------------------ - - ------ ---- - - ---------------------------------------- -- --- - ----- ------ --- -- -- -------- ------ ---.Date � - Final Ins- - - - --•-- -- ----- -------- ------- - ----- ---- -- t. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M