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,FC2R OFFICE USE: APPLICATION FOR SANITATION PERMIT 7o i x t (Complete in Triplicate) Permit No=--------------------- --------------------------------------------------------- This Permit Expires i Year From Date Issued 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 .- # :ls--& A � - ------- - -- ------------------------CENSUS TRACT --------------•----------- Owner's Name --- —--------- _-e/z_ - --------------Phone ------------------------------------ Address ---- ----------------------------- Address _ 'la_ -------- ----------- City _ - ,, Contractor's Name ------ ---- ------- 1 � ------------------------------License # -Y39/e Phone V3:71 '_r-. t- Installation will.-serve: _ Residence [ Apartment House,E] Commercial:❑Trailer Court "F]" x Motel ❑Other ----------------------- -------------------- Number of living units:------------ Number of bedrooms ________Garbage Grinder ------------ Lot Size ZUA---Y_1_.�7a-__--_... Water Supply: Public System and name ------------------------------------------------------------ -----•--- --------------------------------------Private 19 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam 0 Clay Loam.D 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 .[ ] , /_ "Ilk SEPTIC TANK[ ] Size_____-- ___ Liquid .Depth ----------- Capacity 4PIPA- ___-______Capacity - __ Type ____ _ laterial_-��a� o. Compartments _ - ____ -------- Distance to nearest: Well ----t:5 __________________Foundation ..../_Q_f-------- Prop. Line ---Sr_lr___-,_-_--- LEACHING LINE [ No, of Lines -----—7------------- Length of each line------�_O--------_----- Total Length ,_ ...... D' Box _- .______ Type Filter Materialt1G' ----Depth Filter Material ----- ________________________ Distance to nearest: Well __�1_Q_.......... Foundation __/45. ............ Property Line c-67F________________ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -------- -------------------- Rock Filled Yes E] No .0Water Table Depth ------------------------------ -----------------Rock Sze -------------------------------- Distance to nearest: Well ------------------------.---------------Foundation -------------------- Prop. Line -------- ............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------- ------------ SepticTank (Specify Requirements) ------------------- ------------------------------------------------ ------------------------------------------ ----------------------------- Disposal Field (Specify Requirements) ---------------------------------------------------------- ,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 Work an's Compensation laws of California." Signed ----- --- . Owner BY - --- - Title ----------- ---- ---------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...... -- - ------------------------------------------------ ------------------ DATE .-- --- - -- -- 2- ----- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------- --------------DATE -- ------------------------------------ ADDITIONAL COMMENTS - - ------------------------------------------------Z- ---------------------------------- ------- ----------------- ---------------------------------------- --- ----------------------- Fina! Inspection by: ---------------------------- ----------------_-----------------------Date r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M