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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i (Complete in Triplicate) Permit No. --- _ ---- ---------------------- ---------- ---------------------- l�=�� ---------------------------- ------ ---------------- This Permit Expires 1 Year From Date Issued Date Issued 7 jr- Application is hereby trade tc 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATI ----- --------CENSUS TRACT __S_-`if Y__.___________ Owner's Name �C��- = �-zI ---- Phone ---------------- If It Cit �` Addressz l-------- ------- ---- ----- -- y ------ -- Q i Contractor's Name ` 'a✓ r14:_ -------.License # 149-1739-1--Phone ------------------------------ Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court i❑ j Motel ❑ Other --------------------------- -------------- Number of living units ----- Number of bedrooms __ r____Garbage Grinder ---------— Lot Size _______________._______________________ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sa'nd'[] - Silt❑- '"Clay"❑ Peat❑ Sandy Loam y Clay Loam ❑ Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ---------------------------- (Pl'ot 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 -------------------- Material---------------------- No. Compartments -------------_------ �J Distance to nearest: Well ____________________________ p. ----_---Foundation ------------ -- - --__ Prop. ----------------_----- LEACHING LINE [ ) No. of Lines -------------- Length of each line---------------------.------ Total. Length ____________________________ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------..----- Distance to nearesf:'Well ------------------------ Foundation ------------------------ Property Line --_-___-__________---___ SEEPAGE PIT [ j Depth Diameter _______________ Number -----------__-------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .._.____.._-__-_-___-_ REPAIRJADDITION(Prev. Sanitation Permit# --------.----------------------------------- Date -------------------------------__.) Septic Tank (Specify Requirements) ----_-.-. - Disposal Field (Sp my Requiremen#s) �t-4 {� � ------ ----------------------- ---- 'Z-` �--,��- ------C. ....... 1 I----------- - f -------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ -------------------------------------------------------.-------_---__-------------- ----------------------------.,---------------------- (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." Signed --------------------------------------- --------- - --------------- Owner By ------------------------------------------------ mo o ! �'- ' Title ---- .- ------------------------------------------- [If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. ____________ __ DATE -��.�/-y 1.J- -----_--- -- BUILDINGPERMIT ISSUED --------------------------------------------------------------------------- - ------=--------------DATE .-----------------------------------------. ADDITIONAL COMMENTS --------- ------------------------------------------------------------------ -------------------------------------- -------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------=-------------•- --- - = ,rte ---- Final Inspection by: -- ��'� f Date �. f ~1- _` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M