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FOR OFFICE USE:- APPLICATION FOR SANITATION PERMIT Permit No: 4 --- --------------------------------------- (Complete in Triplicate) ------------------------------------- Date Issued __`�= ��z� 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations- CENSUS ADDRESS/LOCATION --------------------------------------- CENSUS TRACT -------------------------- Ovv 10 ��(1l = Phone ----------------- ner's Name d V -I-IV- -1 y y '�'� Q` city /_1- Address r� �j / _ _ `� J --------------------------------------License #�-� -�1�-- Phone -------------- ------------- Contractor's Name - - ..---- Or_=/-F�c/<� '� Installation will serve: Residence� e Apartment Hous ❑ Commercial:F Trailer Court l0 Motel ❑ Other -------------------------------------------- Number of living units:-.-!_.----- Number of bedrooms 3-------Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name ------------------------------------- --------------- - ------Private Character of soil to a depth of 3 feet: Sand W Silt 0 Clay ElPeat ElSandy Loam ❑ Clay Loam El E] Adobe-FJ 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.] ` I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Size ---------------- Capacity F ------------------ Liquid Depth -------------------------- PACKAGE TREATMENT ] ] SEPTIC TANK [ ] --- '.__ No. Compartments ---------------------• I Ca acit - Type ----------------- - Material---`-------------- p Foundatio -------- ------------- Prop. Line _.._. Distance to nearest: Well _______________ ___________• ---- - AA LEACHING LINE [ ] No. of Lines --------------------- Lengfi of each line----------- --------------- Total Length -----------------------• De Filter Material -------------------- •------•- D' Box ------------ Type Filter Mat ial ------------------- p >=oundat' n Property Line --------•.----•--•• Distance to nearest: Wel __---- ----------------- ---------- SEEPAGE PIT [ ] Depth _ Diam er Nu e� ------- Rock Filled Yes ❑ No .0 Water Table Depth ----------------- -------Rock Size -------------------------------- ----•----------- Distance to nearest: W --------------------- --- --------Foundation Prop. Line ` r REPAIR/ADDITION(Prey. Sanitation Permit# - ------ ----------------------------------- date ------•---------------------------) Septic Tank (Specify Requirements) ------ ------ - ------- -- . __ �------ ---d- ------- ------- _ F 'Disposal Field ( pecif Re' ' Y Requirements) --- " ., z� ------------------- -------------------------------------------------- °� -/ ✓ �'' -------------- -------------------------an-------- --------------=----------------------=------------------------------------- - _ - --------- - (Draw existing d required addition on reverse si d e I hereby certify that I have prepared this application and that the work willbedone 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 - Wo an's Compensati. -laws of California." Owner ---- -- - ---------- ------------Signed --- -�' -- - ----- - --------- -------- -- - ------ Title ------- ------------- --------------------- -------- ------------------- -{lf other than owner FOR DEPARTMENT USE ONLY J - APPLICATION ACCEPTED BY -------- - = - = = = ------ DATE --- --------/ -7 BUILDING PERMIT ISSUED --------------------------------------7-------- ---------- - ---------------------------------------------- DAT ADDITIONAL COMMENTS----------------------------- -------------- ----•------------------------ ---------------- -- ----------- ---------- - ------------ - --- -------------------------------------- ------------------------ Date .7 Final Ins ection b SAN JOAQUIN LOCAL HEALTH DISTRICT rr� F H 9 1-'68 Rev. 5M