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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. � ---------------------- ------------------- ------------- � (Complete in Triplicate) - -------------------------------------- --- Date Issued - _.-__ ---------------------- �,J 0This Permit Expires 1 Year From Date Issued r 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/LOCAT Z''k --------------------------------------- -._ ,A�__�G�:--CENSUS TRACT `S''f ------------- l Owner's Name ---- ------ Tt - /" r~ g --- ------ ---Phon ------------------------------ Cit, - ==--------" � Address ---------------`- �� - el------- Cite - Contractor's Name -_____(.�-�>�4- - ��_„-- -- �LC/J� N/may/� `License # / ---- - Phone ------------------------------ Installation will serve: Residence Partment House❑ Com ercial ❑Trailer Court i❑ Motel ❑Other ti ti -- ------(.._ ------------------ ---- ---------- Number of living units:_____�____ Number of bedrooms ___,Y--Garbage Grinder ---__-_-_- Lot Size __6 Water Supply: Public System and name ----------- ------------- ------------------------------------------------------------------------------------Private ` Character of soil to a depth of 3 feet: Sand'❑ Silt[IClay Peat E] Sandy Loam -E] Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill aterial ------------ If yes,type ---------------------------- (Plot plan, sh wing 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,) I d, PACKAGE TREATMENT [ ] SEP T C TANK Size.`, _�1�__ .f---------- Liquid Depth _-_4-------------------- J } Tyr y Material--- Capacity - �^- - Na. Compartments ___ .-.--•----- ff Distance tnear st: Well __________._� �-- --------------Foundation --------/�--i------ Prop. Line ----�•�_.. __..---_-- f LEACHING LINE [ No. of Lines ______l_______________ Length of each line-_.---._�__ E? P------ Total Length ,____ "•------------ 'D' Box -�”-_._ Type Filter Material __. __.._Depth Filter Material ___/_f--------- ____............. _____ Distance toynearest: Well ___ _�___________ Foundation _. -0-i—_.____-__---- Property Line -------_--------------- Distance PIT [i/ Depth __�`- _�__-. Diameter -�3__�__ Number -�X------�- -----JRock Filled Yes ( No I❑ i Water Table Depth ----------------J+q<4 -----------------------•Rock Size o� f Distance to nearest: Well ----------I_ xo----------------------Foundation _.__�_! ......... Prop. Line ___5.............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -._.--._---_._-___. --°"---------`------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ________ _______ ---------------------------------------------------------------------------------------------- ---------------- (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 Wrva� n's Compensation of California." Si ned °.-- Owne 9 -- - - - -- - x 1Title �' ------------------------------- By (If other than owner) FOR DEPARTMENT USE ONLY ----------. DATE _- _-_�-.t'' �" --------------- APPLICATION ACCEPTED BY -- - ._ - _----_ ------------------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------------ DATE ADDITIONAL COMMENTS ---------------------------------------------------------- ----------------------------------------------------------------------------------- ---------------- --------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------- ------------------------------------------------------- -----------------------------------------/-- -+� -- ------------ - - ---------------------------------------------------------------------------- -------=------- ---- - Final Inspection by: --------------------------------------------------- --------------- Date . -`_/�i"_J - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M