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L7110EUSE: APPLICATION FOR SANITATION PERMITPermit No.--__ - t{Complete in Triplicate) Date Issued "- P This Permit Expires 1 Year From Date Issue ----------------- Local Health District for a permit to construct and install the work herein Application is hereby made to the San Joaquin described. This application is made in compliance with County Ordinance No. 5(49 and existing Rules and Regulations: _ ENSUS TRA T -------------- --•-------- JOB'ADDRESS/LOC TIO - --- "�� Phone --------------------------•------- Owner's Nam Address -- Z -�--->--- = cit - -- •,�'o'� Phone License�#�---- - -------- Contractor's Name Installation will serve: Ji Reside ce Apartment House❑ Commercial :❑Trailer Court ',❑ Motel ❑Other ---- --------------------------------•- , Number of living units:__-__ Number of bedrooms ---------Garbs a Grinder ------------ Lot Size ..-° d, " 9 - Private - -------------------- Water Supply: Public System and name _ _ ------______ _ __ la Loam Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Y Hardpan Adobe❑ Fill Material -___- --__ If yes,type ---------- 1 p� lot location of system in relation to wells, be placed on reverse side.) (Plot plan, showing size of buildings, etc. must NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) \' [ ] Size----------------------------- ----- ---- Liquid Depth --------------- PACKAGE TREATMENT SEPTIC TANK'[ ] _____-_ No. Compartments --------------- ------ Capacity i ------- --- --- Type -------------------- Material-- ------- - � Distance to nearest: Well -----_----------------------------- -Foundation _. ------ ------- --.Prop. Line ---- --------�--_.---- LEACHING LINE ] No. of Lines ------------------------ Length of each line--------------------- ------ Total Length ------------ ---------------- 'D' --------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------w Distance to nearest: We ------------------ Foundation ------------------ Property Line ---- --------•------ Proper SEEPAGE PIT [ ] Depth --_---- Diameter ---------------- Number ---------------------------- Rock Filled yes [] No i❑ ------------- -------Rock Size ------------------------ - WaterTable Depth ------------------------------------------------ - Distance to nearest: Well ___________________________•- -- --------Foundation -------------------- Prop. Line ---------------I------ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date - ------•---------•-------•-------) - i Septic Tank (Specify Requirements) ----- =----- -- ----- --------- ---- ; Disposal Fi ld (Specify Re��rements] -fit- E ------------------------------ -- ---- - (Draw existing and required addition on. reverse si cle I hereby certify that I 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. Horne owner or licen- sed agents signature certifies the following-. person in such manner I "I certify that in the performance of the work for which this permit is issued, I shall not employ any r as to become subject to Workman's Compensation laws-of California." Signed - --------------------------- Owner --- ------------------------ e_. ---j -- - -- - -------�- -------- -�------ ----- Title (If of e t an ner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ._ ----- -- -- -- -- -------------------------------------------------------------- DATE `3_(?_-_7 d-------- ------- BUILDING PERMIT ISSUED _________________________ - -----------------------•----------- ADDITIONAL COMMENTS -- ----------------------- -------------------------- ---------- ------- --------------------------------- ----------------------------------------------------7_�-�- ate _ Final Ins pection by: ---- �------- ------- ------- ---------------------------------------------------- ------ - -- - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M