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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -, ------------------- --------------- _ 2- Permit Na: _. . (Complete in Triplitate) ------------ --------------------- ------ --------------- 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 : 5449 and existing Rules and Regulations JOB ADDRESS/LOCATION ------ -- _`-__-- -- -- .�sGG _--.---W WWI'j6�'CENSUS TRACT --------•----------------- Owner's Name --------../� ` ',_�__ ` t ---------------------------------------------------------Phone Address -- �'. �'`-'`i c'� ,� "---------------- City --------------------------------------------•-------•------ Contractor's Name ----- f -v ------- - -------------------License # _�'1 - - - Phone � _ ��. -- 4 Installation will serve: Residence ❑Apartment House❑ Commercial :[frailer Court ',❑ Motel ❑Other ----------------- ------ Number of living units------ ._-Number of bed �_-__�' ! '----_______ WatertrSupply: Public System and name -____-_ -- �•-------� -•--__--------------------------- ----•----------_Private ------------------ e Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ =;.Sandy LoomClay Loam ❑ Hardpan E] Adobe's] Fill Mdtisribl'" If yes, type ---------------------------- (Plot ____ ____________________(PIot 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,} �,a PACKAGE TREATMENT [ ] SEPTIC TANK, Size_ !' �, __:�CLCj__ ------- Liquid Depth ___�_________________ i Capacity1o7'CO rA?,_ Type Material-- No. Compartments ---g-.............. Distance to nearest: Well ___ 4.6-1 _---------___Foundation".fa-----'----- Prop. Line ___---__..---..______ i N f � r LEACHING LINE �}a' No. of Lines ______ems___________ Length of each line.____ ��s-- -___ Total Length ,__ _____.___. 'D' Box -----/---- Type Filter Material 4 _____Depth Filter Material __ _ _____-_-__ ______ _____________ WA �. ---.;...... Distance to nearest: Well _____ G'__________ Foundation _ _-O_- PropertyLine _ SEEPAGE PIT [ }' Depth - -'=----------- Diameter -- ------ ❑ 0 I �_____________ _ Number"_____-.__ . __ _-_ Rock Filled Yes No Water Table Depth ------------- `- ----_---------Rock Size ----:------•------------ Distance to nearest: Well ----------( ____________________Foundation -------------------- Prop. Line _____________._.__.__. k4 REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- --=-----------------�-�-- Date -------------- ------------------ Septic Tank (Specify Requirements[ --------- . y -------- ``` ------ ` .------•-••- e, Disposal Field (Specify Requirements) `---------- -------------------------------------------------------------------- ----------------------------'--------------------------------------------------------------------------------------------r------- ---*----------------'----------------------I------------------------ i (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will.be done in acco dance 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 perforrnance of the work for which this permit is issued, I shalt not employ any porson in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------------- Owner By ------------------ .15•P..�c� � -- ------------------- Title - -------I 4 (If other than owner) ! "� ' , ' . l FOR DEPARTMENT USE ONLY 17kAPPLICATION ACCEPTED BY ---- - - -- ----------------------------------------------------------------------i------. DATE ---�_--�__-�-�=----------------- BUILDING PERMIT ISSUED ______________________ ----------------------------------------------------- --- -->--- ° -- DATA _..-----=---------•-------'-"--`- ADDITIONAL COMMENTS ------------------------ ------------------------------- -_ ' _ -- --------------------------------- - -------------------------------------------------------------------------- -------------- -------------------------------- ------ ------- -- ------------------------------------------------------------------------------------------------------------------- ---- ---- ----- --- - ------ --- ------ ------------------------------ - ------------------------ --------- --- ---- -- llnspection by: -------------- -- - ------Date --- ---- ----- Final. -- --� SAN JOAQUIN LOCAL} HEALTH DISTRICT E. H. 9 . 1-'68 Rev. 5M