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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT /' ---- -- ------------------------------------------ Permit No. (Complete in Triplicate) ` This Permit Expires i Year From Date Issued Date Issued --------------------------------------------------------- { Application is hereby made to the an oaquin Local Health District for a permit to construct and install the work herein E described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: �x-'rz-�t _ -_CENSUS TRACT -._ ---------- JOB ADDRESS/LOCATIOI�� - .-- ----- 11_ - ;- -------L --------------------------------------------` ----------Phone f/7�`_7�PQ_ Owner's Name pp Address r- _Q.' -- 4 - City �O�-J � -7-------------------------------------------- ---------= --- -•- --------------- Contractor's Name =----------- ___-.- - -- - '_- .S a --------.License # A?jO ----- Phone Installation will serve: Res iderice.XApartme-nf�House'❑ Commercial :❑Trailer Court [1 Motel ❑Other -i------------------------------------------- Number ----------------------------- -----------Number of living units:--- Number of bedrooms _-_--Garbage Grinder ------------ Lot Size . --? -- Q_a----------- --- Water Supply: Public System and name Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam 0 Hardpan ❑ Adobe-E] Fill Material --.- ------- If yes, type ---------------------------- (Plot plan, showing size of lotJocation- of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank r seepage pi;t permitted if public sewer is available within 200 feet,) _ PACKAGE TREATMENT [ ] SEPTIC TANK Size.------ _�- ---C-- ------- ------ Liquid Depth ..-- -�--_-- -._. (A} Capocity/zov- ---_��Type -RIP0 Material_( ) G No. Compartments ---------...... ...... Distance to nearest: Well ---t--------------------------------Foundation - ( __ ______ Prop. Line __ _---"f`-.._.-__ U i LEACHING LINE '� No. of Lines ----- --------- Length of each fine------ ��_.______-_- Total Length 177 --,-------------- \ 'D' Box ----- Filter Material -_----04�--- Filter Material ---- ------ --------------- Cey ----- Distan ' r nearest: Well -- --------------- Foundation .- -Q--. `------- Property Line _- ---i`-------- ' SEEPAGE PIT Depth -- Diameter ....... Number Numbe, _.-_--�------.--- -- Rock Filled Yes �' No C] Water Table Djh- ------------------------------- ---•------------Rock Size l y --------- f% _gp itti,_Distance to'nearest.,Well ----------------------------------------Foundation ----j 0-_7`__ Prop. Line -5--_-?t..._... REPAIR/ADDITION(Prev. Sanitation-Permit#. -------- ----------------------------------- Date -----------------------.__---_----) jSeptic Tank (Specify Requirements) - a�--------------------------------------------------------------------------------------------------- -----------------------_-•- Disposal Field (Specify Requirements ---- -------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- ------------------------------------------------------------------------------------------------ ----------------------------------- ----- ------------------------------------------ ----- --------------------- 1 -------------------------------------------------- - ---•- (Draw existing and required addition on revefse side) 1 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: (11.- € "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 subject;to Workman's Compensation laws of California.'.' . I Signed ----------- ------ Owner t - �rt� - BY ---- Title__' -- --------------- - ---- ------------------------------------------- (If other t owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .- - ---Nah - ------ ------------------------------------------- ----------- DATE -----5` IP--ela2--------------- BUILDING PERMIT ISSUED --- ----------- - ----------------------------------------DATE - --- ------------------------------------- ADDiTIONAL COMMENTS ----------------- ------------------------- ---------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- ------------------------------ ---------------- ------------------ ---------- -- . ---- ---------------------------------------- ,: 9 - �„ ' ----------------------------- ------------------------------------------------- --i----- ---- Finalinspection by: -------------------------------------------------------•-••------------------------------------ -Date ------------------------ —-. - ---------- S/J7�7g SAN JOAQUIN LOCAL HEALTH DISTRICT IV"X75_1 I 'r- E. H. 9 1- 68 Rev. 5M