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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate) Permit No. _�.__. ------------------------------ - ---- --------------- ---------_-----------------____________________________- This Permit Expires 7 Year From Date Issued Date Issued ./'�'= y_�.3 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. JOB ADDRESS/LOCATION ._-//W__Y__,-__-�- _ f �` _ �� a_r�lT� '-so. -- a/�f-----CENSUS rtRACT -------------------------- Owner's Name _._ ! '✓� /. ,f___-__G.� ' T = _ _ �.,t, >�= -=r== = -------Phone -- ----------------- ............... Address --- -- �-O- Ap r-----� e.....-- ----------------------•- City�.t r, t,,� - � __-------------------- Contractor's Name ---� e _. a, ��.___.License # -..2 Phone Phone Installation will serve Residence ❑ Apartment House,❑ CommercialArailer Court I Motel ❑ Other --- Number of living units:---'. Number of bedrooms _:`_-___Garbage Grinder ____ __ Lot Size ___��_�`_��:------------ I _ __ _� Water Supply: Public System and name _______� ____._ -_ ��_________ '____ j f I ------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ �► Clay [] Peat f� Sandy Loam.-E] , Clay Loam ❑ f V / \ Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type---------------------------- (Plot plan, showing size of lot, location of system in trelation 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,) . PACKAGE TREATMENT . SEPTIC TANK t E e .:.• { 7 L �' Size S+C-r------------- Liquid Depth --------------------- Capacity __/-Apo---- Type+ ��iBSTMaterial-__S llle4e�_�-No. Compartments ____�__.:_ Distance to nearest: Well _________, ___________________Foundation __. _�2___.__ ____ Prop. Line ___. LEACHING LINE { ] tNo. of Lines ------------1_1_.,_Lenglh of `ch line---------------------------- Total Leng— — ' 'D' Box /z;;0--- Type Filter Material ��_��__ -_-Depth Filter Material ............................... Distance to nearest: Well.___5V............. Foundation ___/__Q___ Property Line ___...4------ i �y SEEPAGE PIT [ ] Depth ___----------_------ Diameter _____________ Number ---------------------------- Rock Filled Yes ❑ No i❑ r Water,tTable Depth ------------------------------------------------Rock Size ---------------------------- Distance ---------- --- --- - -----•Distance to nearest: Well _______________________________________Foundation _..--_-------------- Prop. Line ---------- .......... REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------------------------------ - --- - Date ----------------------------------1 � Septic Tank (Specify Requirements) -'- j 16 DisposalField (Specify Requirements) ----------------------------------------------------------------------------------- - --------------- -------•--------------- � ----------------------------------------------- --'�--------------------------------------------------------------------------------.--------------------- ------------------- ------------------------ ----------------------------------- - - --------------- ------ -- (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: "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 becom ect to orkman's Compen anon laws of California." Signed '------- �-_'------ Owner By ----------------------------------- -- ---- �----- - Title -- - '------------------ -- (If other th n er) \ D-W MENT-US ONLY APPLICATION ACCEPTED BY ....... DATE BUILDINGPERMIT ISSUED - -----------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------ ----- ------------------ ----------- -- = _ _ - -----------------------------------� ( Final Inspection b = - = ----- ------ -- -- ------ --------- Date SAN JOAQUIN LOCAL HEALTH D RICT E. H. 9 1-'68 Rev. 5M