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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT x = =�-------- Permit No7, (Complete in Tr .Triplicate) Permit ---------=---------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued __�.l_—�___�_�0 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 comp)' nce with County Ordinance No. 54 n xi ing Rules and Regulations: JOB ADDRESS/LOCATION .---4>—,(D--Y-,Z- - ---------------CENSUS TRACT --------------------- Owner's Name --------- - -- - ----------------------------- ---- -------------Phone --- Address ----------- - ------- �- - city ------ ---- ----------------------- -- ' Contractor's Name _ _ ._ _ _ __ ___�__ ___ __ _ f/___ C.�_-License # ��__-__ Phone �6 Installation will serve: Residence D<Apartment House,[:] Commercial ❑Trailer Court Motel ❑Other------ ------------------------------------- Number ------------R-------------- --Number of living units:__-- ----- Number of bedrooms --_?----Garbage Grinder ---- Lot Size -------- Water Supply: Public System and name-----------------------------------------------------------------------------------------------------------------Prlvatex,_ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material --- -------If yes, type --------- ---- -- (Plot 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 ke age permitted if public sewer is available within 200 feet,) r PACKAGE TREATMENT [ SEPTIC TANK Size------------------------------------------------- Liquid Depth .________________-____.... LJ� Capacity --------------- Type -------------------- Material-----------=---------- No. Compartments ---------------------- 6 ante to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING -_. -LEACHING LINE &19114. of Lines ------------------------tLength of each line-----------------------------Total Length ,___________-________________ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------------------.-___ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------------------------- 91 SEEPAGE PIT [ ] Depth ________________ Diameter _______________ Number ____________________________ Rock Filled Yes ❑ No l❑ U Water Table Depth ------------------------------------------------Rock Size ________________________________ Distance to nearest: Well ----------------------------------------Foundation ----_--------------- Prop. Line ----------------.----- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________:_________________________) Septic Tank (Specify Requirements) --------- AJ ---------- ----------------- -- ---- Di osal Field pacify Require ents) ----- - - - ---- ------- - -- ----- ----- ` - Q---0.--,& / � 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. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of th work for which this permit is issued, I shall not employ any person in such manner as to bec a subject t orkm n's C pensa laws C io." Signed ` BY -------------T---------- ------------------------------ (If other than owner) RTMENT USE ONLY g I APPLICATION ACCEPTED BY --------Z - ------ --- --- -------------------------------------- ---- -------- DATE ` BUILDING PERMIT ISSUED ---------- - ------ --- •-... i ......--- /� � --� ------------------ = ------- --------------DATE -------------------- ------------------ ADDITIONALCOMMENTS ---- -- ------------ - - ----- -- ----------------------- ------------------------------------------------- --------------------------- -----------------------------------------r--- -------------------------------------------------------------------------- -- -------- Z - - - ------------ Final Inspection by W- - -------Date -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT F. H. 9 1-'68 Rev. 5M