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JFOOFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: _-__--•___-- {Complete in Triplicate} --- ---------- ----------------------------------- --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to theISan Joaquin Local Health District for a permit to construct and install the work herein . _described. This application is mace in compliance twith County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._. l 3 tj "" CENSUS TRACT Owner's Name --- tg / A a ------------Phone •---.-... Address _.-_ __ ---2 (/YU_ �•V f --- ----------------------------------------------- :2 -- ---- ---- - - city Contractor's Name ---- ---- r ----- ------------------- -.License # .�/1_3Y 7!Phone ------------------------------ Installation will serve: Residence [L�partment House IF Commercial : Trailer Court EJ Motel ❑ Other . - Number of living units:________ N'mber of bedrooms ______Garbage Grinder ------------ Lot Size .._. _________ Water Supply: Public System and name -------------------------------------------------- ---------- ------------------------ Private Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay .❑ Peat E] Sandy Loam �ay Loam ❑ Hardpan ❑ Adobe.❑ 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 ltank or seep ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK [ Size-_-__X..�______X 2;57�_ ------------- Liquid Depth ----y-_____------------- CapacityType - MaterialNo. Compartments _121- 7 ...........•. V Distance to nearest: Well -------------S'c5-r----------_---Foundation L. _ ________ Prop. Line ____-�Z------------- LEACHING --___-_____LEACHING LINE [ No. of Lines ----- ------------- Length of each line-----..S!_!.____----__ Total Length ..__-67-0_______________ f� D' Box __.,_______- Type Filter Material --------51 _Depth Filter Material ---------1_�,-------------- Distance to nearest: Well ------- ------ Foundation ---I_L1_____---------- Property Line ----,.�-_______________ SEEPAGE PIT [ j Depth _____-__--_---_-___ Diameter ________________ Number _______ ------ Rock Filled Yes El No 0 Water Table Depth -------------------------------------------- "..Rack Size --- -------------------••---- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------_--_.-.------ REPAIR/ADDITION(Prev. Sanitationi Permit# -------------------------------------------- Date ---------------------------------- Septic ---------------------•----------Septic Tank (Specify Requirements) _________________________-_ ------------------------------------------------------------------------------------------------ -- Disposal Field (Specify Requirements)- ___________________ ------------------------------ .+ --- ---------------------------------------------------------- ------------------------------------------------------'-----------------------------------------------------------------------•------------ ----------------------------------- ---------------------=------------------------------------------------- ----------------------------------------------------------------------------------- ----- (Drow 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: t "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." Signed - - Owner-------------------------------- BY E -fR-- �`-- -------- Title -- -------------- -------------- ----------- --------------------- (If other than owner)- FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BYBUILDING DATE PERMITISSUED ----------- ----------------------------------------------------------------------------=----------- --DATE -------- ---------- ----------------------- ADDITIONAL COMMENTS -- . - --------- ------------------------ -------------------------------------------------------------------------------------- --------------------------------------------------------------- ----- --- ------------------------------------ - ---- --- -------------- ---------------------------------- Final Inspection by ----------------------------------- -------------------------------- ------- --- -- ------ ------------------------------ --- -- -------- ------ --: - =------- --------------------------------------- ------- - - ------------------Date --/}-" �` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M " "