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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------- Permit No. ---------=---------------------------------------------- I (Complete in Triplicate) ---------------- This Permit Expires 1 Year From Date Issued Date Issued __L-------_---:_7 Application is hereby made to the;San Joaquin Local Health District for a permit to construct and install the work herein described. This_9pplication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I JOB ADDRESS/LOCATION .---------- CENSUS TRACT ____ __. - -. --------------------------------------------------------------- i Owner's Name _J-I?-I? ----�I"V /'_---U1e_1V-- �------------------7- --- -- ------Phonec��- Address - off ------- V�1 12 a City -� /�J Contractor's Name .- ------------------------------------License # ------------------------- Phone ---------------------------•-- Installation will serve: Residence ❑ Apartment House❑ Commercial :MTrailer Court ;❑ F-1Other -- --------- ---- -------------------------- Number of livinits:-----/----- Number of bedrooms _______Garbage Grinder ------------ Lot Size ---- -_WatWater er Supply: Public System and name --------------------------------------------------------------------------------------------------------Private t Character of soil to a depth of 3 feet: Sand'Z Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe C 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 [ ] SEPTIC TANK [ ] Size_________ _________________________ ----- Liquid Depth _____-_______-______ Capacity ------------------ Type -------------------- M rial-------------- ------ No. Compartments ------_--- -- iDistance io nearest: Well ----------------------- ------------Foun tion ---------------------- Prop. Line ---------- :-------- LEACHING LINE [ ] No, of Lines ___________ ___________ Length of each fine___ ----------------------- Total Length ,__________ 'D' Box --------- Type Filter Material ___________________ epth Filter Material _ Distance to nearest: Well ________ _________ Foun tion ________________________ Property Line, _--_-_----_-_--__-_-._- � SEEPAGE PIT [ ] Depth ____I_______________ Diameter _______________ N ber ---------------------------- Rock Filled Yes ❑ No Water Tal le Depth ----------- ------------------------- ----------Rock Size -------------------------------- Distance to nearest: Well __________________________ _____________Foundation -------------------- Prop. Line ..........____.-__---_ REPAIR/ADDITION(Prev. Sanitation Permit# _. -_-_ -- ---- ------------- Date _-__--_-____-__-_--_______________} } Septic Tank (Specify Requirements) --------- ------ ------------------------------------------------------------------------------------- ' Disposal Field (Specify Requirements) --- ------------------------------------------------------ -- ---------------------- Kiri �C- ------d �ty e3--- ----1C1- - P-------------------- ./f?J _I__- ---- -------- I (Draw existing and required addition on reverse side) I 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 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 issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." SignedI -----------A --------------------. Owner c' By ------- ----------------- Title -------------- - ------------------------------------------------------- (If other than owner)l t +( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- C----------------------------- --- --- ---------------- DATE =7?— - ------------------ BUILDING PERMIT ISSUED ------------ ------------- --- DATE -------------__-___ _ ------------------------------------------------------------------ -------------------- ADDITIONAL COMMENTS ------------ ------------------------------------L --------------------------- ------------------------------------------- --- ---- .------------------- ------:-------------- _ ------------------ -------------------- ----------- ------------------------- ----- --- -- - ----- ------------------------------- ---------------------- ------------- -- --- --- -- ------ ----- - -------------------- ---------------------- -- - Final Inspection by: ----- ------ ------------ -------- ----- - ---.Date ---- r 7 - C . SAN JOAQUIN LOCAL HEALTH DISTRICT ! E. H. 9•ti 1-'68 Rev. 5M