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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) - --�--!_o--__-- -_----_------------------------- -------------------- - This Permit Expires 1 Year From Date Issued 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. 5.49 and existing Rules and Regulations: <- u` JOB ADDRESS/LOCATION ----------- _ _ Fi - ------------ ------------CENSUS TRACT --------------_---------- Owner's Name -------'—M_ Jv, ---------------- -------------------------------------------Phonei Address 4 fir-- -- -------------- Citr_&_,(!_ ------------------------------------------------ q 9 � '- 0y -------/' Contractor's Name - -� t=. C` � ��- License # Phone Installation will serve: Residence W Apartment House❑ Commercial :❑Trailer Court l❑ Motel ❑ Other ---------------------------------------- -- pp _ Number of living units:----- Number of bedrooms ______Garbage Grinder ------------ Lot Size ___ ( ..... -_-f -��-----•- 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 __________________________(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,) NO PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ------ --------------.-_-. Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------_-_----- Distance to nearest: Well ____-----__---___________________Foundation ---------------------- Prop. Line ____:____----_:________ LEACHING LINE [� No. of Lines -__-____-�_ _--- Length of each line_______ ----------- Total Length ,_____�,��_____________ �1 'D' Sox __ -_ �_____ Type Filter Material Filter Material -------- ---el Distance to nearest: Well -------r��----- Foundation ----- _-C1---1----- Property Line - ....... I SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No '❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well _______________________________________Foundation _______---_- ------ Prop. Line .._______-_______.____ EPA ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date --------.-----.------------------_} Septic Tank (Specify Requirements) ----------------------------------------------------.------- --------------------- ----------------------7 ----------------------------- I r l/1 Disposal Field (Specify Requirements) ___C ---- -- -------- ------------------------------------------------------------------------------- ------------ --------------------------------------------------------------- ---------- ------ -------- (Draw existing and required addition on reverse side) 1 heroby certify. that-1 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 Hcen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit isoissued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California:" Signed --------------------------- Owner - L � Title ----------- SY (If other than owner) FOR DEPARTMENT SE ONLY APPLICATION ACCEPTED 13Y ------------ 40 ¢1 DATE -_----10- -71----------------- BUILDING PERMIT ISSUED ---------------------------------- -- ------ ----- -- ------------DATE -------- ------------:-------------------- ADDITIONALCOMMENTS ---------------------------------- ---- ------ -- - ------------------------------------------ ------------ ----------------------------------------------- --------- ------------------------`-------------------- ------------------------------------------------------------------------- --------------------------------- ----------- Final Inspection by: ----------------------------------------------------------------=--- -------- = = Date -_._11i�- - � ~ SAN-JOAQUIN LOCAL HEALTH .D RICT - E. H. 9 1-'68 Rev. 5M