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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- � -----------------��r�7--� - � Permit No: -------- --------------- - (Complete'in Triplicate} �---------=--- ----- --- ----- -� Date Issued �-'-3�_:?z _-__-_-_- -_-- - 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 ._ *! _ G,�t. ----- ---- ------------ ------------..CENSUS TRACT Owner's Name ------ - PhoneAddress -------vim c - City ---------------------------------------------- .t Contractor's Name ----- - ✓�-----------------------------License # Xjo� Installation will serve: Residence 'Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number ------------------------------------------Number of living units:--/-:--- Number of bedrooms -____1_Garbage Grinder Lot Size `_ s --f1�---------- 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 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet) ! [- PACKAGE TREATMENT I ] SEPTIC TANK Af Size__ _ -- -------------------- Liquid Depth0_�-.-----_-_ --_-__- FAp-- --- TYpeCapacity/ aterial-4 -4 �_ No. Compartments _ ______/_ sr _______ Distance to nearest: Well ____------- _______________Foundation _,/.&---------------Prop. Line _.:-------- tlt"1 LEACHING LINE r%Q No. of Lines __._.-_�---___.____ Length of each line--;-a------------------- Total Length`_�1,49.-----______,__. , _ Type Filter Material/t_ Filter Material le�-----------------------•--�.---- D' Box Depth Fi -------_-'-- Distance to nearest: Well ___________________ Foundation ------__-------- Property Line SEEPAGE PIT [1[j Depth __ _ ----- Diameter - - .____ Number --___�---------`------- Rock Filled Yes No i❑ � -- " _Rock a Water-Table-Depth -------------------------------------- t f -'------------ Distance to nearest: Well -----`d--------------------------Foundation ----Z --------- Prop. Line ------------- REPAIR/ADDITION REPAIR/ADDITION (Prev. Sanitation Permit* -------------------------------------------- Date ----------------------------------} Septic TankTJSpbcify Requirements) ------------------- --------------------------------- --------------------------- .-------------------------- DisposalField {Specify Requirements} ----------------------------------------- --------------------------------------------------- ------ -------------------------- 5 ""a k r -------------------------------- -------------------- - - - - - - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the"work-will-be-do_ne-in-accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Locaf 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,Ml shall-not-employ any person in such manner as to become subject to Workman's Compensation laws-of California." Signed ------- { ------------ Owner »- --- ---------------- --- ---- ----------------------- -- Br -- ----- ---------------- Y ----------------------- ---- - --- ------s---4-`-------------- - ------- Title - - ---�-`-•-- - [ her than ownei) � I `A FOR DEPARTMENT USE ONLY - •;�. -. APPLICATION ACCEPTED BY _. - - -',--------- DATE /--------------------------------- BUILDING PERMIT`ISSUED ---_-------- ------- --------------------------------------------------- DATE / a ADDITIONAL COMMENTS - �i. '1 1-- __ -- -----_-------------I - ----------- ------------------------------------------------------- ---------- -- -- ------------------ -------------------------------------- ----------- -- = = -.,M------------------------- ---=------- Final inspection by.,------------------------ ------- -- -- ---- - -- to(CAL t Date a Wiz- SAN�JOAQUIN� HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ►