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FOR OFFICE USE: � ®,., ,APPLICATION FOR SANITATION PERMIT pp ------- ---------- (Complete in Triplicate) Permit No. - 4-2-1-0 ---------------------- ----------- 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 Ordina a No. 549 and existing Rules and Regulations: / JOB ADDRESS/LOCA N �fJ ----------------CENSUS TRACT ____�._�_ _ !� /�' - � Owner's Name _ �-1 G.,-' �� Phone__ Pho -___ Address ------- - - --- - >/ /� r - -------• City ,rev;/1^� ------------ -- _ - -- �� Contractor's Name _- \ ��"" __-_---.License # �_ p� yPhone __ ________ Installation will serve: Residence �rtment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------------------- Number of living units:---------1 - Number of bedrooms --,3---.-Garbage Grinder ---- Lot Size - --------- Water Supply: Public System and name --____-__-_ F Sandy Loam Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ eat❑ a y ❑ Clay Loam ❑ / Hardpan E] Adobe i I 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,) O10 PACKAGE TREATMENT [ ] SEPTIC TANK.[ ] Size-----------_-----------------------.-.---------- Liquid Depth -------------------------- "-,6 Capacity -------------------- Type -------------------- Material-------------------- No. Compartments - V ance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... LEACHINGLl E Yof Lines ---------------------------Length of each line---------------------------- Total Length ---------------------------- Box ------------ T YP e Filter Material __________________De P th Filter Material -------------------------------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PI� [ Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes '❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well _.--------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------_ ____________ -Date _ _ ___________ ____- ------ Septic Tank (Specify Requirements) -------------- - ... --------- - -------------- -------- Disposal -Disposal Field (Specify Requirements) ------- - - --------V F - -------- f�s� ----------------------------------- ------------------------------------------------ ---------- ------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 -- ----------- Title - --/ -- - Y ------------------- ' —= - --------=_------------------- - E/ '--------------- ------------ (I t an owner) /OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------------------------. DATE `��- -- ----------------- BUILDING PERMIT ISSUED ------------ - --------------DATE -------- ---------------------------------- ADDITIONALCOMMENTS ----------------------------- --------------------- ------------------------------------------------------------------------------------------------------ ----------------------------------- ---------- ------ ------------------------------------------------------------------------------------------------------------------------ - - ------ --------------------------------------------------------------------------- Final Inspection by: L erc� --------- - --- - ------------------------------------------------- ---------------------Date - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M