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FOR OFFICE USE: �- ---------- -- ass APPLICATION FOR SANITATION PERMIT - ' Permit No. -�- __-- - .___. 3 ,Completo in Tripliiate) ------------------------------------------------- _______- ----__ This Permit Ei<pires 1 Year Flom 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 ADDRESSAOCATION ._-_ ___4,f�_-- G� ,, a -- ------- ,-_-_ CENSUS TRACT -------------------------- Owner's Name � - ------------------------------------------------ ------------------------------------Phone------------------------------------ 1 - Address ---- ` ' - -------- ---- . City -. - ------ -------------- Contractor's Name ---,/ � p�/ d--- °------------------------.License Phone - ` Installation will serve: ResidenceApartment House E],Commercial:❑Trailer Court 0 Motel ❑ Other ----------- Number of living units:...r___.- Number of bedrooms %-,*?------Garbage Grinder _/ __ Lot Size pr_A& - __-____________. Water Supply: Public System and name ----------------------------------- -------------------------------------------------------------_-----------PrivateA Character of soil to a depth of 3 feet: Sand'EJ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ r Hardpan ❑ Adobe ' Fill 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.l NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer available within 200 feet,] E PACKAGE TREATMENT [ ] SEPTIC TANK Q ize= ° --------------------- Liquid Depth __'��________________ Ca acit / `f---- T- e Compartments Y �� i Yp - - ;--__-_ Material-��____ No. Compartments -________ ___.____ Distance"to nearest: Wel! ___ � ______________•Foundation 7X_--__ s_ Prop. Line ---�----------- i _ � l a � �, LEACHING LINE No. of Lines ! ' Length' of each IEne__ -_ _----:------ Total;,length -11;1419- - / L�--------------- 'D' Sox tnearest: 1" Type Filter Material,' fd Depth Filter Material _ `-------------------------- Dista ______________________________ Distance Well ____, --------- Foundation -------- ---- Property Line ' 'r SEEPAGE PIT ] Depth ---��--_-- Diameter _7------ Number ___---_-__ '1''�_'____ Filled ,i' No C I - Rock Yes Water able Depth ------- � fx ------------- Distance ,-- � �4 ��----- ------------------- Rock Size �---`---�- ---------- , � r- f f Distance to nearest: Well ___- -------Fo'undation ___---______- Prop. Line _ __ ________________ ; REPAIR/ADDITION(Prev. Sanitation Permii# --------------------------------------``s-r Date ---------------------------------- Septic -------------_--------------- --_Septic Tank (Specify Requirements) ---------------------------------------=----------—-------------------------- - I a Disposal Field (Specify Requirements) ] f = ------- -=--=------ ---------------------------- •--------------- ---------------- -------------- ----------------------------------- -------- ----------------- - ----------------------------- `----- ---------------•-------------------- -- ---L` - (Draw existing and required addition on reverse side) FT. c r 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 liven- a sed agents signature certifies the following: "L 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." - Si .gned ----- --- -------- - Owner 4 r BYti = ' ------------------------- Title _. other than owner] r' ' _ FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY ------ ------ ---' - ------:Y--------------- ..... DATE ------- BUILDING PERMIT ISSUED ---------------- ----- DATE ---__-_-- .-_------ --------------------------------- - -----------COMMENTS [ ----------- �! -------------------------------------- -- -------------------------------------------------------r'-?- ' - -------------------- ------------------------------------------------- /,(�y� - E------------------------------------------------------------ Final Inspection by: ------------ - -- rt ----------------..t Date --------------- -- SAN JO-AQUIN LOCAL HEALTH DISTRICT E. H: 9 1-'68 Rev. 5M