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FOR OFFICE USE,:,, ewl APPLICATION FOR SANITATION PERMIT Permit No.. = 0 J (Complete in Triplicate) / --- Date Issued/, "i ------------- 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 __ _' �.--_. ____ lC�_(�_l� t t i c ___ ___ ____ -----------_------CENSUS TRT ______ Vl Phone .__ - x I ? ------- Owner's Name -.� _' �= _ - ----- -- t -------------•- - -SA-S-11 Address City == �' 1 Contractor's Name - _F'f ! c cit------- ------ ------.License #. �7 � :_ Phone ' =------ Installation Installation will serve: ResidenceApartment House,❑°Commercial ❑Trailer Court 0 Motel' Other ------------------ ------------ Number of living units:--- --- Number of bedrooms ..1----._Garbage Gander Lot Size ..2--< 0............ Water Supply: Public System and name ---- �� !T �- 4' T ----------- Private ❑. Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay 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 tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------;----------- Liquid Depth .___.__-----_-,---------- Capacity -------------------- Type -------------------- Material----------- --------- No. Compartments -------_--------•--- _ .Qistance to nearest: Well -----------------------------------Foundation ---------------------- Prop. Line ---------------------- LEAC14ING LINE T No. of Lines __.____-_ ___ _ gth of each line______`(_._-_____-------- Total Length ,___�,�_�.:___--•-------•- Len D' Box _-�{s Type Filter Material _,___ �r�_u:.Depth Filter Material ______- ----•---------•i- Distance to nearest: Well _)__%__k__==____-- Foundation ______ __�.'__________ Property Line _____................... SEEPAGE PIT F1 Depth _ . F'_ _.. _.__ Diameter ___=5__j__-_.-- Number __'_____._._�--------- ---- Rock Filled Yes No i[] f ,.__ Water Table Depth -------------- ---------------------------Rock Size ------ =__ --------------- Distance to nearest: Well --_______----------Foundation ____�_�2_'__...._ Prop. Line __.. ............... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------- ------ , -- -- Date ------------------,---------------- Septic Tank (Specify Requirements) __._ ------------------------------------------------------------------- -------------------------)- ------- �------ )----�------`--�-----`-----:-------_--- - Dis osal Field (Specify Requirements) -------�a-� ----------=�--n----------� ------}------------ � 4 ��,..{__-.-___---__--______-.____--______-____----____-______-__-____-_________.___________________._-___________. ____.�________________________ _____________ ___________________________________________ --------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 -,---------------------------------------_------ -------------------------- -------------------. Owner B 1� x_k_ Title ------------------------------------------------------- (If other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '1'C- --------G�--42.JLr�------------------------------------------------ DAT ----------- BUILDING PERMIT ISSUED ------------------------- ! ---------------DATE ------------- ------------------------- - - ------------- ----- ------------------- ADDITIONALCOMMENTS ---------------------- ---- ---------�-�--------------------------i--------------------------------------------------------- ---------------------------------------------------- ------------------------------------ ----------------------------------------- --------------------------- ------ - ---------- --------------------- - J Final Inspection by: __ - -------------- - - --------- - -- ------------------.Date ----- ------------------- -�,�-'-'--- SAN JOAQUIN LOCAL HEALTH DISTRICT 1-'68 Rev. 5M