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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ___/� ---------=---------- - -- - -� --------------------- - 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: JAB ADDRESS/LOCATION . ____ _ _ T/_/J✓_fP�+ ii � ----CENSUS TRACT --------------__ ��C .-- - Owner's Name _ --------�1471 A1! -------------------- -----------------------------------Phone /1 - 1' '. ------ �ez7e#*----------- Address -------- Q-��.r_--- X----'-F��`�---------------------------------------- -------•--. city -------- - - - Contractor's Name ----7Z7 ---------------------------------------------------------License ____ Phone&G_ '' G Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court // Motel ❑Other --- f-- v, ft -- Number of living units:---l------ Number of bedrooms ........ Grinder ."----- Lot Size ----40.4 C<e ....... Water Supply: Public System and name ------------ --------------------------- ------------- -------•------------------------------------------Private Character of soil to a depth of 3 feet: Sand'E6 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 seeps a pit permitted i�pub�ic sewers availab,�y��ithin 200 feet,) �� PACKAGE TREATMENT [ ] SEPTIC TANK,[ Size/___ Depth __ _ _________ Capacity/..-:310--._,__ Typ/042 __ Material6PAY.e.6,-No. Compartments - -J --- ---_---------- Distance to nearest: Well __ A'____________-----------Foundation _� __ _________ Prop. Line• ...__ LEACHING LINE [4]� No. of Lines ____ Lengthy of each line____�Q__--_-..--__ Total Length _ 1t7wo0 D' Box Y ___ Type Filter Material . Q -------Depth Filter Material --------------------le-_-• Distance to nearest: Well ___ ® �__, _ ;_ Foundatigf"�__ -------------- Property Line !PZ -------------- SEEPAGE --- ---------SEEPAGE PIT [ ] Depth -------------------- Diameter ----------- Number ,--------.------------------ Rock Filled Yes ❑ No C] Water Table Depth -----------------t------ -1 --------------- .......Rock Size -------------------------------- � Distance to nearest: Well ___________________ _____,Foundation-------------.------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date --____--_____-___________.__.-____) t' SepticTank (Specify Requirements) ------------------------------- ---- ------------------------------••---------------------------------------•--------------- ............. Disposal Field (Specify Requirements) -----------------------------------------------------------------------------x--------------------------------------- ----------- -------------------------------------------------------------------------------------------------------- --------------------------- -----------------------------=------------------------ F sar ------------- ----- --------------------------- - ------ . ------------------------------------------------------------------------------------------- . (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 BY - q-- 6 �, -." --- Title (if ther than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- - -' -- --- --------------------- ---------- l7 -------------. DATE ----•l` -7- --------------- BUILDING PERMIT ISSUED ----------------------------------------------------------- --------------------- --------------DATE ------- -------------------- -------------- - ADDITIONALCOMMENTS -------------------------------------------------------------------- ----------------------------- -------------------------- ------------- -------------------------------- ---------------- ----------------------------------------------------------------------- ------------------------------------------------------ ------------------------ ----------------------------- --------------------- --- - - - - - - - - - - - ----- ---------------------- Final Inspection by: ------------- - L ------------------------------------------------ --------------------Date _ Z= j SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.-9-- 1-'68 Rev. 5M