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FOR OFFICE 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 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: / / ,Q rX----_----CENSUS TRACT _----5- 1-----_-_ JOB ADDRESS/LOCATION __6___l'�_c�-,_.� ____I� __ _, __ __ --. Owner's Name . ' ,�` .. hone . --- ---------------- G n , AddressC. ._,. . City - - - -------------------- Contractor's Name __ c _,� �,__ -. -------_-_-_-.License #��a11-��'"_ Phone _ _y_/__$_ ------ Installation will serve 'esidence j9 Apartment House❑ Commercial ElTrailer Court i0 .> Motel ❑Other -------------------------------------= Number of living wits:____ _-__ Number of bedrooms--,I-------Gcrrbagq' Grinder ________ Lot Size _______________________ Water Supply: Public-System and name --- - --- ------ ------- - --- ----- -------------- - ------------•--_-------Private f Character of soil to a'depth of 3 feet: Sand'(] Silt❑ Clay ❑ Peat❑ Sandy Loam' Clay Loam ❑ Hardpan (] Adobe'E] Fill Material ____ ______ If yes,type ---------------------------- (Plot _________ _____ _____ __(Plot plan, showing size of lot, location of system in relation xo wells, buildings, efc. must be placed on reverse side.) " ' NEW INSTALLATION: (No septic tank or seepage pit permitte.t.f lrc sewer is"available within 200 feet,) ` O PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size ___ Liquid Depth __y?__._.. Capacity C'; - ' Type7. _Cr; � terial_Q_ ., No. Compartments ,I... Distance to neare3t:,Well _____ Foundation _____ ______________ Pro Line ___ 47 i ... LEACHING LINE [ ] No. of Lines ------",' -------------- Length of each line,------ ------------- Total Length ,_..,2 ?_�............. D' Box _____(____ Type Filter Matstl,alDepth Filter Material --------I. .............................. Distance to nearest: Well _______ Foufidation _______ ______________ Property Line _____-__-_____._ --_..._ SEEPAGE PIT [ ] Depth ------------------- ;;Diameter ______________ _ 14umber _- _______ _____-_____ Rock Filled Yes ']] No C) Water Table Depth ------------------------------------------------Rock Size ----------------------•--.------ Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ________-._.__.------- REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ___.__-._______-_.___.._________._) Septic Tank (Specify Requirements) ______ -__ __II~te '' f ' Dispos I Field Specify Requirements) --- .__.._ $- �c. _ ---s_12_ ,, ____d-,r_s,2..__ _, _1(_ ?------------ --------- - -- - - ----------------------------------------------------- - --------------- ----------------- -------------------------- - ------ ----- ----------------------------------------- ------------------------------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -- -G ,'------------------------------------------------ Title - ---------------------------------------------------------------------------- Owner / BY ------- -- - - - _- ----� --' .t; �_cwt `=------------------ ----------------------------------- (If other than o� nen) Uzi FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- ---- -- --------- -- ---- ------------ DATE' ' BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------ --------------DATE ADDITIONAL COMMENTS ----------------------------------------------------- -------------------------------- --------------------- --------------------------------------------------------------------------•-------- ------------------------------------------------------ -- -------------------------------------------------------------- -------------------------------------------------- --------- -------------------- ------------------------------------------- ----------- - - ------------------------------------ Final - - - - ------- Ins ection b _ Date --r__/$ __ _-___- - ----- - ----------------------------- --- -----P Y Z�l.a:y -- / -.�' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M