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i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i --------- ----------- ------------------------- (Complete in Triplicate) Permit No. --2------------------ , � 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1. JOB A�DDRESS/LOCATIO .--�1_tf -- .-------------- ---- ----------- - -- CENSUS TRACT r • - Owner's Name ----- ` --------- -- Phone - _______._ ___ _ ___________ __________n_; _ ,� y . Address ---- - J�v�_�"z- _ �t Contractor's Name , --- --- a �---e-- -�-- License # _/�g,3k2 ---- Phone i Installation will serve: Resides [Apartment House❑ Commercial ❑Trailer Court i❑ [ Motel ❑Other -------------------------------- -- Number of living units:------1---- Number of bedrooms __W----•Garbage Grinder ------------ Lot Size -------------------------------------------- Watel Supply: Public System and name ----------------------------------------------------------------------------------------------_-------- ------Private INCharacter of soil to a depth of 3 feet: Sand'❑ Silt[] Clay FW1 Peat E] Sandy Loam ❑ Clay Loam r I Hardpan ❑ Adobe-❑ Fill Material ___________ If yes,type ---------------------------- (Plot ______________-___(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,) V PACKAGE TREATMENT [ ] SEPTIC TANK''{� Size_�(�__ _. ____-_5- ------------- Liquid Depth ___-----------..______..__ � _ Y , ' Capacity _ ab_4_. --- Type --- ---- Material.- ---- No. Compartments -_---�_---.---- � ----------------- ---------- ------- Distance to nearest: Well ______ Foundation _--��--rProp. r LEACHING LINE ( No. of Lines _____ __ Length, S Total Len ,-_-- Sa of each line ------ gth ---------------- I _ Ff { 'D' Box --- ------ Type'Filter Material ---gAi------Depth Filter Material -------1-�1-------------------------------- Distance to nearest: Well -- 5-iq Foundation ------t19--------- ---- Property Line _nF---------------_-- SIT [ Depth ------1 ----------- mer v---------J`---- Number --------- ------------- Rock Filled Yes No 0 IPJ I ' Water Table Depth '---------�41----------------------Rock Size �_/� 'Y '� �+ F 5 Distance to nearest: Well -------------J_ ©_ ...............Foundation ___I2___________ Prop. Line ..._______._____..._.. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------- --•----------•----..----------------------- Disposal Field (Specify Requirements) ------------ --------------------------------------------------- --------------------------------------------------------------------- --------------------------------:-------- ---- - ----- ------------- -- ---- -------------- ----------------- I�. -----------------------------------------------------------________________________ ___________________________ __________________________________ (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- k sed agents signature certifies the following: F`1 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." i' I Owner Signed -------- ------------- - =��-+-r- , -- - - -- ------ By ---: i �-�- Title --- (If other than owner) FOR DEPARTMENT USE ONLY ------------ APPLICATION ACCEPTED BY --------------------------------------------------------------- --. DATE 7 BUILDING PERMIT ISSUED ------------------------- - ------------------------DATE ----- ------------------------------------- -- - ------------ - ADDITIONAL COMMENTS ------------------ ---- ------------------------------------- ----- ------------------------------------------------ ,I K_ __ -- -------------------------------- ------------------------------------------ al: --------- '[---------------------- r-----/t_ _ ____ Final Inspection by: Date ------- --- ,--- - ___Y___________ _________ ____ ____________________________._____.________________________________ . SAN JOAQUIN LOCAL HEALTH DISTRICT E. W19 1-'68 Rev. 5M .