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FOR OFFICE USE: - ' APPLICATION FOR SANITATION PERMIT - �oS Permit No ----- . . (Complete in Triplicate) - Date Issued -/O"_.�7 "2.1— 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 OrdinanceNo. 49 and a fisting Rules and Regulations:- _ /� JOB ADDRESS/LOCATION -1--- �r'�"` f�` � ENSUS TRACT ".7. Owner's Name �JG � - --------------- Phone i� R - Address = ------------ Con#rector's Name --.----_.License # `- � Phone ` -"" ''! -- . i Installation will serve: Residence Apartment House,Cj Commercial :❑Trailer Court ❑ Motel ❑ Other ----X------ - ------ Number of living units:--" "--- Number of bedrooms --__`".Garbage'Grinder Lot Size - Water Supply: Public System and name ------------'------------" ---------------- Private Character of soil to a depth of 3 feet: Sand❑ ,Silt.❑. Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- {Plot plan, showing size of lot, location of system in relation to wellsbuildings, etc. must be placed on reverse side.] , •��r NEW INSTALLATION: [Na septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT { ] SEPTIC TANK:( ] Size-------------------------------------- Liquid Depth -.----.----------y---:f• Capacity - Type ------------------- , Material---------------------- No. Compartments A ---Foundation ----------------------jrc . Line -------------- ' � Distance to nearest: Well ---------------------- ___""""-- I? , ,- � ----- Total Len fih -------------- ------'"•��-- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line__-------------------- 3 - . .w •w p --------------- ------ 'D' Box -------.-__ Type Fit#e�1�laterial�-------" th Filter Material p; f Distance to nearest; Well --"""-__"-" Pro erty' ine ------------------- Foundation - Rock jFillec� Yes ❑ No } ---- Diameter Number ,❑ • SEEPAGE PIT [ ] Depth ---------------------- Water ."___.- -- - WaterTable Depth' ----------------------------------- ---------•'Rock Size ------------------------------ s Distance to nearest: Well ---------------------- Foundation -------------------- "Prop"*Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date, -___------ ---------------------]�, Septic Tank (Specify Requirements) ------------------- y - - - ------------ `e w Disposal Field (Specify Requirements] 4 P -- -------- ------ - - """-"--""""; : -.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 signaturecertifies 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 subiect to Workman's Compensation laws of California." + Own erSigned --- ---- -- ----- - Title - ---------- ----------- o t erFthan own r) a ` J.l t '� FOR DEPARTMENT USE ONLY + Ft APPLICATION ACCEPT -D BY -E 'r DATE' -` `'. BUILDING PERMIT ISSUED -----`---------------------- -------------------------- -------------- ---------------------DATE --- ` ----------- --------- ADDITIONAL COMMENTS E ` -- ''�= --------------- •-------------- --- --------- --------- --------------- ---------- _ -------------------- ------- ----------------- -------------- - ----�- Final Inspection bY�=e�.�`=- ----- -- --�-��------------------------------------------------------- --------- ---------- ---- / ---�------- Date °2-----�'- --- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ` \ � ;, ; ►