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v Y POR'OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------- ----------------------------------------- j !1 (Complete in Triplicate) ' Permit No. ---------------------------------------------------- I i _________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued 1- > Application is hereby made to the San Joaquin Local Health District for a permit to constructzand install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules afRegulations: D11 /-40-7 f JOB ADDRESS/LOCATION ._ l r__ --(�- ---0 �e^5---'. _r` - -!__...0 NSU�RACT ----k ---------.. Owner's Name ------�/ =�" �, = Phone C -- , ' / ------ City' ✓_: ------------------ -------- ------ Address ----- '-------------- ---' - - �--- - -------• �j-ryry �-- Contractor's Name ._- !__- _ ---. __---------------------------------------------License / f Phone Installation will serve: Residenceartment House❑ Commercial :❑Trailer Court ❑ t s Motel ❑Other -------------------------------------------- Number of living units:________ Number of be s -------- .Garbage rinder _..__ Lot Size / �-- - Water Supply: Public System and name -------- ---- ------- � -------------------------------------------- ❑ -- --- Private Character of soil to a depth of 3 feet; Sand'❑ Silt Clay Peat F] Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe' Fill Material_�L'` If yes,type ------------------------- -- {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,) r PACKAGE TREATMENT [ ] SEPTIC TANK Size _ ___ _____ ________________ Liquid Depth __ ateria� r Io. Compartments ___�.-_--:_--- Capacity - -- - Type .-�'- -- �"'f� D' ante to nearest; Well __ ------Fourrdation ___ if'_________- Prop. Line ___ ____�-__--__ l I LEACHING LINE ` ' No. of Lines --- ------ Length of ach line. — _r __ Total Len th � __�. r 'D' Box --- Type Filter Material __ __,Depth Filter Material __-_ '--- �____ ---------_______ �.. / , istanc to nearest: Well _____�______-_-___ Foundation __. _r______ Property Line-_'__ ' SEEPAGE PIT:Depth --------- TDiameter Number ____ _______ Rock Filled Yes No i❑ Water Table Depth ----jt---�-------------------------- -------Rock Size - �� Vii/ �•-- # Distance to nearest: Well ______��_________1___`__Foundation _`Q____�____ Prop. Line J.................. REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------------b_ Date ---------------------------------_) Septic Tank (Specify Requirements) ------------------------------------------------------------------------ ;------------------------------------------------ _� _ Disposal Field (Specify Requirements) ----------- ---------------------------------------------------------------------------------- ------------------------------- --------------------------------- ---- -- --------------------------------------------------------------------------------------- ---- --------- « ___ (Draw existing and required addition on reverseiside) � ) 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 iwsuch manner as to become subject to Workman's Compensation laws of California." Signed ...... ---- -- ------- ---------------------------. Owner I iBY ------- ------- ------- - -------- - --�.��-- ----------------------- Title � � - --'�------ ---- �------------------- ------ (If other t �wner) FOR DEPARTMENT USEF ONLY APPLICATION ACCEPTED BY ____ -------------------------------- DATE �• � - ------- BUILDING PERMIT ISSUED ---------------------------------- -- �- -. ----------------------- --------------DATE ----------'-------------------------------- ADDITIONAL COMMENTS -----------------------------------------------------------=-----=--------- ----------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ---------------------------- -- - ------------------------------------------------------------------------------------------------ -- Final Inspection by: ------Date ~ SAN JOAQUIN LOCAL HEALTH DISTRICT! i E. H. 9 1-'68 Rev. 5M + ;