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w. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- --- -- - --------------------------------- - �.�_`_1�� (Complete in Triplicate) Permit No: _ ---------------------------------------------- Date Issued This Permit Expires 1 Year From Date Issued----------------- i 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 existin i Ryle s and ReguIItions: f Gf fli�/is JOB ADDRESS/LOCATION __l fl__®_/1J__ 1--T1�_ "" __/ I��/C�1/ ____."CENSUS TRACT ______________________.. - 7 Owner's NamM/ -- ---------------------------------------------- ------------- -.."-,---------------Phone me ' _ ---C�cr i Y _ -- Address - - - - - -�-- ------------------------• Cit - - ��------- Contractor's Name W -----�-----vY-` --------j---� License # Phone pd`�---- -- Installation will serve: Residence ❑Apartment House ❑ Commercial :❑Trailer Court i❑ jMotel ❑Other ------------------------------------------.. Number of living units----- Number of bedrooms ---_G-__ arba e Grinder ------------ Lot Size 1 ` '___________ Water Supply: Public System and name ----------------------------------------------------------------------------------------- -----•--- -----------Private Character of soil to a depth of 3 feet: Sand'E` Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ . Hardpan ❑ Adobe•❑ Fill Material ------------ If yes, type ---------------------------- �r (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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size_ { � [ ] X--5----?�'--�-U --- ---- Liquid Depth -- --y'-----••--••-- Capacity —.5-074!----- Type �-_-_ -_ -- Material � ____ No.,Compartments ��_ _______:__.. Distance to nearest: Well ------. -- --------------Foundation _1.�_____--------- Prop. Line ------------ LEACHING LINE [ ] No. of Lines ------/-------------- Length of each line..... _____________ Total Length :_ Q............... r lr 'D' Box ------------ Type Filter Material ---1�_ __ _______ epth Filter Material ` Materi P / ___ Distance to nearest: Well --------- Foundation l_ _ __ Property tYLine ___7�_____ SEEPAGE _ F PIT [ ] Depth ____________________ Diameter ________________ Number ___.____-.__.__________.___ Rock Filled Yes ❑ No I[] Water Table Depth ------------------------------------------------Rock Size ------ ------------------------- Distance to nearest: Well _____________________________Foundation ------- Prop. Line __________________-__- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) -------- ------- ------------- ------------------------------------ ----------------------------- --------------------------- Disposal Field (Specify Requirements) ---------------------------•----------------------------- ----------------------------------- v - ------------ r-------------------------------------------------------- --- - ----- - (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 Work an Compensgtiion laws of California." Signed _ _ ________ - Owner w V BY ------- ---- - ------- -------------------- ----- Title ------------------------------- ------------------ -------------------- ------------------------------- -------- (If other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -—_ ---------------------------------• DATE _./ 1-'� ?X---------- BUILDINGPERMIT ISSUED ------ ------------------- -------------------------------------------------------------- ----------------DATE ------------------------------------------- ADDITIONAL COMMENTS ! ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- ------------------------------------- Final Ins ection b - Date w�T� P Y - ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT a E. H. 9 1-'68 Rev. 5M y 1