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FOR OFFICE USE: 7/ APPLICATION FOR SANITATION PERMIT A 7 -- ' ------------ ------ L` i Permit No: l ------------- I ' �--- s. (Complete in Triplicate) = - .____._____.___ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin LocalHealthDistrict 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: JOB ADDRESS/LOCAT N ------ r - ---------�-. `-_----=--- _ .. u-CENSUS TRACT -------------------------- Owner's ii Name _r ---f _ --------Phone --�,2 Address -- ------------ ------:�.-------- t� .' s�s� r-- City --- Contractor's Name.. _ s- Phone--_-- - ------License Installation will serve: ! ,Residence PfApartment House❑ Commercial :❑Trailer Court 0 Motel ❑ Other --------------------------------------------- Number ------------------------------ ---------- f Number of living units:____ __ Number of bedr oms ___sa�-___Garbage Grinder _. Lot Size �z � �_(___��_�.. Water Supply: Public System and name --------- K� L- I - ------------_------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .EJ Hardpan ❑ AdobeX Fill Material ------------ If yes, type ---------------------------- v1 Mot plan, showing-size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Notseptic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ]% SEPTIC TANK'[ ] �clIs' rS`Ste------------------------------------- --------- Liquid Depth ----------.. _--- .-.--- � ' Capacity - ------------4-- Type -----------i--- Material-------------- ------ No. Compartments ---------------•---•-- ' 'Distance to nearest: Well ------------------------------------Foundation ____.__________-____ Prop. Line ___________-- ........ LEACHING LINE No. of Lines .____� ____ Length of each line______��__1 -_____ Total Length .--�/Q e - ---------- ----------------- De Depth Filter Material �r I Q' Boz -:--� Type Filter Material _1014 -- - -- P ----��-------.......------••--------•- i Distance to nearest: Well _ __ ____________ oundation __f0___ ________ Property Line. -----�_� ...._...... .__ SEEPAGE PIT Depth __ :�`�` ___ Diameter _ __�- Number � i❑ Rock Filled Yes No i Water Table Depth ----------- ---------_______________________Rock Size ---------------- --------•___-- Distance to nearest: Well -----��`��, • �� ------Foundation -- 4.___� --- Prop. Line ______.. ri � . REPAIR/ADDITION(Prev. Sanitation Permit# --------- __1_________ __________ Date----------------------------------- Septic Tank (Specify Requirements) �� L ....... Disposal Field (Specify Requirements) ---- _- _ ___-_____ � a per-- --- ------------ -- - ---- --------------- ---------------------------- - ------------------------------------------------------------------------------------------------- (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 signature certifies the following: r "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------ - ------------ ------------------- ------ • ------------------ Owner By ------------------------ /�� - e. (If of er than owner) ft - ----------- --------- Title ----- G;----- ----- - ------------------------ ' FOR DEPARTMENT USE ONLY [ J ` BUILDING PERMIT ISSUED ----- --------�`-------- ------------------------- --------------------- -------DATE -----�/- /^-.--�----------------- APPLICATION ACCEPTED BY-. DATE AL COMMENTS ----- -------------------3-------------------------------------------------------------'--------------------------------------'--------------------------------------------------------------------------------- - t ----------------------------------------- ----- - - -----------------------------------------------------------------------------------------'_------------------- 3 Final Inspection by: -----==--------------- ----------'-- ----------...------------------ -------------►------.Date -----�_`__-1='�._--__---- - ----- SAN JOAQUIN LOCAL HEALTH DISTRICT - E. H. 9 7-'b8 Rev, 5M C`}�--