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j FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- - -" --- ----- - --- - - -------------- " 5 '3 0- (Comp a in Triplicate) Permit No. a -- -�-'3--�----- -------tom- ----------------- Date Issued _-__--__ __-- __-__-____ _ _--__-_ This Permit Expires 1 Year From 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 .-5-/--- b-F,. - .f2_� AFf---------------- ---------------------CENSUS T�RAOT Owner's Name --- -----✓ ------------------------------------------------------------ ----- one -'---------------------------------- .� ,,RPh Address -- �-�6-�'7--Ga-`- -------------�---------------------------------- City ---�/ `444)eF----,---------------------------------- 44 Contractor's Name ______ ' License #�f�� _ PhoAe _y _______._.__-.-- Installation ill serve: Re s-id-en c e Apa ri ment House❑ Commercial ❑Trailer Court [, Motel ❑Othor ----------------------------------------- IY�_ Lot Size __� -----------. . _ C_ � Number of living units:----/_----- Number of bedrooms _____Garbage. Grinder _ _ __ _ Water Supply: Public System and name ._ � � _._ �__S- +°' �---- --- -;i---Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ `Adobe;< Fill Material ------------ If yes,type ---------------------------- (Plot ____ _-__-_ __________(Plot plan showing size of lot, location of system in relation to wells, buildings, etc.,must b'b'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 f ] Size-----------------_------------------------------ Liquid Depth -________.______-___----_- Ca.pacity ---------------- Type -------------------- Material---------------------- No. Compartments ------------------.-_- Distance to nearest: Well ------------------------------------Foundation ____________________ Prop. Line ---------------------- LEACHING -_________-_______ _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 -------------__p___ Diameter ________________ Number ---- Rock Filled Yes ❑ No WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -------------------- -------------------------------------------- ---- --- -- --------- ------- ---- Disposal Field (Specify Requirements) _._ --z-------�,/j- ----------�._ _c� -----_ .��'�0---` ; ------------------------ -------------------------------------------- ----------------- -------------------------------------------------------------------------------------------- --------- ------ (Draw existing and required addition on reverse sidef 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 *ealth District. Home owner or licen- sed agents signature certifies the following: ----i "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 -------------------------------------- ------ Title -`----------------------------------- By ` (If other th caner) ` FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------------------- DATE ----------- BUILDING PERMIT ISSUED ---------------------------- � - -- ------- --- ----- ------------.-DATE ------------- ----------------------------- ADDITIONALCOMMENTS ------------------------------------------------------- --------------- ------------------------------------------------- ------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------- r-r , --- ------------ --- �------ - - - - - - ------- -- ------------------------ - -- ---- - ---- --- - - -- Final Inspection by: -- -- ------ --- ------- ------------------------------- ------Date ---- SAN J QUIN LOCAL HEALTH DISTRICT ' E. H. 9 V-'68 Rev. 5M