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::.,, FOR OFFICE USE: '✓ - APPLICATION FOR SANITATION PERMIT ,r - -----_- (Complete in Triplicate) Permit No. k T-0 This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 CGS ------ ---------- ------------------- CENSUS TRACT i Owner's Name ,----- "` `---------------------------------------------------------------------- Phone Address e,aG��Iiv� --- -------- City 2— 'SContractor's Name '--------- - ------------ -- ----�------------------------------License # � 7 -_ Phone _'�6 `T'------------- Installation will serve: Residence (-partment House❑ Commercial {Trailer Court i❑ !: Motel ❑ Other -------------------------------------------- Number of living units:------ Number of bedrooms --1-------Garbage Grinders ----- Lot Size -------------------------------- ------------ Water Supply: Public Systemx and name - ---------- ------------------------- ------------------------------------- ------Private, ❑ Character of soil to a depth of 3 feet: Sand;❑ Silt❑ Cla ❑ Peat El Sandy Loam ❑ Clay Loam E]Hardpan❑ Adobe ill Material --_--------- if yes,type ------------------- ----- (PI'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 [ I SEPTIC TANK [ I Size------------------------------------------------ Liquid Depth ---------------------,----- O Capacity __ ............... Type -------------------- Material----------- No. Compartments Distarke to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------__- .r------ LEACHING LINE [ ] No. of Lines ---Y_------------------ Length of each line--------------------- Total Length -----------................. } 'D' Box ----._4 Type Filter Material --------------------Depth Filter Material ___________________ ............ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -_-__--.--__--_.--._..__ SEEPAGE PIT [ ] I Depth --------------------I Diameter. ---------------- Number -------- _---_-------_---- Rock Filled Yes 0 No C Water Table Depth -------------------------------------------------- ' Rock Size ------- -------------------•---- + Distance to nearest: Well ----------------------------------------Foundation --------------- Prop. Line ----------------:----- REPAIR/ADDITION(Prev. Sanitation Permit# --------_----F--------- ---------- --€-- Date ----------------------------------) r` Septic Tank (Specify Requirements) -------------------------------------------- - - ------------- ----------------------------:----------------_ ---------�--------------- Risposal Field (SpecifyR Requirements) ______ ---- -�'�.-__-_-- _�_�_►�s�--- 1 -!-.------' ---- 'f_?5-- ----------- k ------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- F ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- {Draw existing and required addition on reverse side) i I hereby certify thatkl have prepared this application and that the .work will be done in accordance with San Joaquin i 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." r Signed --..-____ Owner By --------- - ---- -------- Title -------- ----- (lf other than ow er) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ------------------------------------------------------------------ DATE ------ -2 - �- � ,6�-------- BUILDING PERMIT ISSUED t__ iv ------- --------- DATE ---------- -- ---------------- ADDITIONAL COMMENTS - S---�-3�-----------�1 ----------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- -------------- ------------------------- --- - - Final Inspection by: - -------------------------------------------------- -------------- ------- -------- ----------Date _ T �-- - I---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.