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FOR OFFICE US E APPLICATION FOR SANITATION PERMIT �fpp Permit No: --�- I ----------------------------------- -------- (Complete in Triplicate) I� Date Issued /7- _ This Permit Ex ires 1 Year From Date Issued _� --------- p Application is hereby made Yo the San Joaquin Local Health District for a permit to construct and install the work herein •cation is made in with_County Ordinance No. 549 and existing Rules and Regulations: �_ described. This applic R,c4 - __ _ ... -- - -- CENSUS TRACT -5-- ------•----------- JOB ADDRESS/LOCATION �'� r ------.Phone ------------------------------------ Owner's Name �j e-;_.�4 -- -------- City . Address -------sv_q�,_4. C.° �- one � __ _ _---,----.License # �-�`-�-�►'Y Ph Contractor's Name .-----e Installation will-serve. Residence- Apartment-House,❑-Commercial'❑Trdiler Court if Motel ❑"Other ------------------------------------ =- Number of living units:_"_b --- Numher of bedrooms --"--..-.-..Garbage Grinder ------------ Lot Size -------=---"-- --------------- Number ----- - s ------- Private { P e � ----------------- --------- Water Supply: Pvblic�System and name-:..._.._--"-------------•--------- -�- - -- ------ Clay Peat❑ Sandy Loam ❑ Clay Loam:❑ Character of soil to a depth of 3 feet:- Sand❑ ❑ Y ❑ t 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.] I 4/ r NEW INSTALLATION:; (No sep""tic tank;or seepage pit permitted if public sewer is available within 200 feet,) .� s . Liquid Depth ---------------------- ' S1=PTIC�ANK'[ ] Size--------------------------------- -•---- ----- q P PACKAGE TREATMENT [ ] ----._ Material--------------- ---- No. Compartments -•------------•- I Ca acit - Type [ ' Distance to nearest: Well ---------------------------- 1=ounclatio`n---- ..--------Prop. Line ---------- ------- Distance .* e i Length of each line------.-- - Total Length -----------•-•-- LEACHING LINE [ ] No. of Lines 1_----------------- -- 9 , + --�-- - --- --� "t' De the Filter:Material ---_.--- D' Box ------- -- Type Filter Material -.------------ 4� Line Property .;------------------•----- Distance to nearest: Well ------------------------ Foundation --------------- --- P rtY Depth Diameter -__"_.._-.-.-_ Number .-_------------- --- --Rock Filled Yes [3 No .❑ SEEPAGE PIT [ } p i Water Table Depth ------- RockSize - F k :.Foundation - x rop. Line -----------•-- ------ e Distance to nearest: Well ---..__.--..----- y s 1 REPAIR/ADDI'FiON[Prev. Sanitation Permit ---------- -------- te . (. . s Septic Tank (Specify Requirements) ------- - --------- ---- - - 4 a iisposal Field (Specify Requirements) --------------�----" r �. t: "- (D aw existing and required addition on reverse side) e in accordance with San Joaquin I'hereby certify that I have prepared this application and that the work will be don County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sedagents signature certifies the following: ".I y e for which this permit is issued, I shall not employ any person. in such manner certif 'ha"'n thperformance of the work [ as to beco s bject to Workman's Compensation laws of California." } I + S! Owner Signed /'-vim s Title' _ ------------------- t By fi j (If other than owner) �.. F { FOR D PARTMENT USE,ONLY ' �7 / � DATE f APPLICATION ACCEPTED BY --- ---------DATE --------------------------------------- BUILDING ------ ---------------------- -------BUILDING PERMIT ISSUED --------------------- ------------------------------------- --------------------------- ADDITIONAL COMMENTS -------------------- ------------------------------------------------------------------------ ' -- --- - ------- ---- ------------ --- -- --- - ---------------- ------------------------- E ------ -- - ----------------- -------- -------- -------- ------- �` - --- -------- -------- ------- ------- ------- ------- ------ -----Date Final Inspection bY: ._. -- - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M. _