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f ar FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ----------------------------- -- (Ce/f omplete in Triplicate) --•----------------------------------------------- � Date Issued This Permit Expires 1 Year From 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 ma 7de in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION - _`_Fg--- �_ -- tee t_--� --- ---------------CENSUS TRACT --------------•----------- Owner's Name ----- --- .-------= Phone ------------------------------------ 0 1 Address 7 _ 1 �----------- City - ` J 1 .. Contractor's Name __.._ -- --"___-��- --�----=--.License # ��,3� ----- Phone --------------•--------------- r Instailation•will-serve:—Residen- -[+ artment_House Commercial ❑T.railer:Co.urfi0 T fMotel ❑ Other -----�----�--'--------------------------- Number of living units:--_-I__-_ Number of bedrooms __-t'"`-•Garbage Grinder ------------ Lot Size ._s�� =.. ------ Water --— " Water Supply: Public System and name --------------------------- --------t '_ == - - -_------Private - - - -------------------------- ---------- Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay Pea El-e Sandy Loam ❑ Clay Loam.0 h Hardpan ❑ Adobe-E] Fill Material ______-_._ _ if yes, type ______________-"__________ I. {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 _permiffed if public sewer is,available within 200 feet,) V PACKAGE TREATMENT [ I SEPTIC TANK;( Size------------------------------ ------- Liquid Depth -------------------------- Ca acit Type ` Material �------- No. Compartments ------•---------- p y --------- - yp Distance to nearest: Well ------------------------------------Foundation ----------------------.Prop. Line ,-------------------- LEACHING -------- -------•LEACHING LINE [ ] No. of Lines ----i------------------�L•ength of each line--------- `------------- -- Total Length --------_------------------- 'D' Box ------------ -Type Filter Material i_______ Depth-Filter Material _____________________________••------------- Distance to nearest: Well ____________________ i , ! FoGridation Property Line, ________________________ .� a.�� ------------------------ SEEPAGE PIT [ ] Depth -------------------- Water -------------T_--=- Diameter ---------------- NumbeT� -4 �`-----,----- ---- Rock Filled Yes No .i❑ r Water Table Depth -------------- '' ___Rock S;ze ------------------------- Distance to nearest: Well ------------------------------------•- Foundation --------------- Prop. Line -------_------------- I REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------------- ) i � Septic Tank (Specify Requirements) ---------- -------------------------------- ----------------------------------------` Disposal Field (Specify Requirements) _________ ---------------------------------------------------------- ---- --------------- ----"""""----- Jr c F ____ __ _ ________"_________-________-______"________"______y4___________ --- ----------------------------------- FF -------------------____________ ___________----__-_ _ _ _ (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 Workman's Compensation laws of California." Signed --- ------------------------ --- ---------- --------------- - ------ --------------- Owner �g u By -- --- ---- ----------------------- `c `` L'- - Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE _- - r��- ----------- -- - -- ----------------------------------------- BUILDING PERMIT ISSUED ------------------- _DATE -------------•----------------------------- ----------------------------------------------- ADDITIONAL COMMENTS ---------------------- ----------------------------- ----------------------------------------- ------------ ------------------------------------- t -------------------------- ----- i ------------ ---------------------------------- -- ---------- _ Final Inspection by: " -- -----------Date l Cf` ----- - ------ ------- SAN ,JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.