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FOR OFFICE USE: Y APPLICATION.FOR SANITATION PERMIT -- -- ----- - ------- -- ----------------------------- Permit No. .. r�- d (Complete in Triplicate) -=- ------------- ---------------------------- ------------- _----------_-_---------------------------- 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. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION .-- r� F,r l7/� ---------------------- ---------------------------------- -CENSUS TRACT ------------------..--_-. �_ :_f7 -- Owner's Name _._�_�j��/_�---�_O��S-D --------------------------------------------------------------- -- -- --Phone T�';��--�--------- Address - �------------------------------------------- City 5 Contractor's Name --�, --- ------------------------License # _.1� g�'-- -- Phone Installationwill serve: Residence,®Apartment House❑ Commercial ❑Trailer Court Motel ❑Other ------------------------------------ ------- 40� Number of living units------ _..-_ Number of bedrooms -_2.___-Garbage Grinder �G-_-_ Lot Size _7-�Xl___________________________ Water Supply: Public System and name -------- - -`--------------------------------------------------------•--------------------------------------Private ❑ Character of soil to a depth of 3 feet: - Sand'E] Silt 0 -Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ Adobes Fill Material ------------- If yes,type -------_----_---_----------- (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,) U PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ----------------_ Capacity -------------------- Type --------------------- Material---------------------- No. Compartments ---------------------- C Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------.___-__ LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- -Total Length .______-___________-____-____ 'D' Box --------'---- Type Filter Material --------------------Depth Filter Material -------------------------------------------- . Distance to nearest: Well ________________________ Foundation ________________________ Property Line _______________-__._.___ SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ____________________________ Rock Filled Yes ❑ No i0 . w Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation ______ ---------- Prop. Line .---___--__..___-.__- REPAIR/ADDITION(Prev. Sanitation Permit# ----------- -------------------------- Date ----------------------..__.-_---__) Septic Tank {Specify Requirements) ____ __________________________________________ Disposal Field {Specify Requirements) __-/P ___A'/SS_'jJ ___� _ 1t111__�/y��T _________________ _.. "--------------------------------------------------------------------------------------=------------------------ ------------- --------- 1 2 Al 1 n--- - 5 s s-'Af------ �r C > e-4 B >< t� -� (DraAisfing and require ddition on reverse side) I hereby certify that I have prepared this application and th t the work will be done in accordance'with San Joaq County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Men- 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 becoAletman's Compensation laws of California." Signed -- --- ------------------------------------------------------------- Owner By -------------------- ------------ -Title ----------- ----- ----------------------------------------- wner) 4 R ENT USE ONLY APPLICATION ACCEPTED BY ------ - --------- --- --- ---- --- - ----------------------------------------------- DATE TI ------------------ BUILDING PERMIT ISSUED ------- - ----- ---- -=- - ---------------------------------- --- ------- DATE ------------------------------------------- ----- -- ---------- ADDITIONALCOMMENTS ----- -- -- - ---- --- - ------ -- - --------- ---------------------------------------------------------------------------------------------------------- - =' ----------------------- -- - -- -------------------------- ------------------------------------------------ ----------------- --- f ------ - -- - ------------------------------------------------ ---------- -------------- -- . Final Inspection bY' -------- ------------ - ate " =1�--------------------- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M !