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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT a----------- -- Permit No. (Complete in Triplicate) ---------------------------- ---------i _ Issued This Permit Expires 1 Year From Date Issued Date ��,�� ---... ' ------------------------------------------------------ I,= Application is hereby madeYothe San Joaquin Local Health District for a permit to construct and install the work herein described. This application Is made in compliance with County Ordiriance No. 549 and existing Rules and Regulations: Q JOB ADDRESS/LOC TION - _- IJ- -. f - CENSUS TRACT -----------------•--__---- -- Phone -------- Owner's Name --.__- - ----------- �'j Address _ = ' - ` =`°_.�-•=:-GtY- ✓------------------------------- ---------- i ' t __ r -� �� Contractor's Name --- ------ ----------- ------- -------------------------------- License # --�; Phone = i Installation will serve: Residence Apartment House'❑ Comte' ercial :❑Trailer Court i❑ Motel ❑Other -------------------------- r------------- Number of living units:- ____ _-_ Number of b oom Z� Garbage Gri der/�1W___ Lot Size� -Y- - -20--------- /11 Water Supply: Public System` and name -------- 7/- - - --------------� Private ❑ �1 : r. Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E] :Peat E] Sandy Loa ❑ Clay Loam ❑ Hardpan ❑ AdobeI Material ----- ------ If yes, type __________________.____---- (Plot plan, showing size of;l'ot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: . (Nol e ptic tank or seepage pit permitted if sewer is available within 200 feet,)PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size-------lublic f------------------------------ Liquid Depth ------------------------- Capa ------------------ city -- TypPe, = ------ Material---r---- ------------- No'. Compartments ------ --------------- Distapce to nearest: Well ,_-""" `-"""' _------__.Foundation ---------------------- Prop. Line --- --------_----- LEACH'ING LINE [ ] No, of Lines _____.___________ Length of each line__------------------___ Total Length-- Len 9 ----------- ----------_---- ' 'D' Box ---- ---- Type Filter'Material --------------------Depth Filter Material. __.--------------------- .-------=- Distance to nearest: Well --------------------- Foundation l_______________.__._{Property Line ----------------- SEEPAGE PIT [ ) Depot h ---- -----------°-- Diameter __________,____ Number ___ -- ---_.__-_--- Rock Filled Yes ❑ No ❑ Water Table Depth ------------ -------- '--------------------------------- -Rock Size ----------------?----------•---- i ...—-.r Distance to nearest: Well .' =____` "'-- _�y_— ___----_-_Foundation -------------------- Prop. Line _________________ IN. `� w REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- -------------------------- Date ___________________--------------) Septic Tank (Specify Requirements) ----------------------------------- ------ ----- { ------------- :-. --------- • ------------ ---------- 1911 r Disposal Field (Specify Requirements) __________ -- - --- --- r , I� ---- ------------------------------------------------ --------- ------------------ F , _______________________ -_-- _____ 11 ' I (Draw existing and required addition on reverse side) k I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Slate Laws, and Rules and Regulations of the Son 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' ssued, I shall not employ any person in such manner E as to become subject to Workman's Compensation laws of California.'" Signed ----------------------- -- ---- I� ---- Owner '4 '_ -------- Title _._ - .. fs�c�; . ------------------------- By ------------------------------ - - - - -- r a 4 Of of r an'owner) IM FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY = -- - ----------------------------- ---. . DATE --�'�BUILDING PERMIT ISSUED.l1--=J------------------7a---f------------------------- __ ---------------- -DATE ------------ ------------------------------ ADDITIONAL COMMENTS 0-- --------------- ------- ------------------------------------------ r --------------------------- — — ' a I ' -----�-------TD-- --' ------k Inspection b --- --------- ------- Qate --------------------------� - -------.._---- P y -� 1 SAN JOAQUIN LOCAL HEALTH DISTRICTN+� "" E. H 9 1-'68 kev. 5M