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FOOFF! U ----------� tG APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .�'-_�� _ ---------------�- -;L- 1-- - --------I This Permit Expires 1 Year From Date Issued Date Issued SC."NED 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 wjth County Ordinance Np. 549 and existing Rules and Regulations: JOB'ADDRESS/LOCATI N ---_ - Q� �, ------ CENSUS TRACT-__- _ ------------ -- ----------- ---- -- ------ --------------------- /------------------ Owner's Name - ' �_( -S`77- ----- l.7 ---- --- - --- ---------------------------------------------------------- -------Phone _ ---- Address - I - - ------ -- --------------- Cit Contractor's Name -____---- _ -"- --- __License # /00,S// �///�� -Q ___ - - - ---- Phone Z_Q---7 - - - -------- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other Number of living units:_---I------ Number of bedrooms ________GarbagSt e riner Lote Water Supply: Public System and name . _ IV - !-----------------Private ❑ Y ❑ Y Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay ❑ Peat❑ Sand Loam` Clay Loam ❑ Hardpan ❑ Adobe X 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 pi seepage a e t permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK - [ l Size------------------------------------ ------------ Liquid Depth --- r4 Capacity Capacity ,------------ Type -------------------- Material------------------- No. Compartments ------- Distance to nearest: Well ------------------------------------Foundation ---.__-_----__-__-_ Prop. Line __-.______.._______ LEACHING LINE --- [ ] No. of Linbs _- ------- Length of each line--------------------------- Total Length ------------_ D' Sox ------------ Type Filter Material --------------------Depth Filter Material -_-_--_--_-_ ---------------- ------ Distance to nearest: Well___-_____-______-___ Foundation __.---___-..-_________ Property Line ----------------- _ _ � --- - SEEPAGE PIT [ ] Depth --------------------- Diameter -------------- Number __ _--__- _____-_-____ Rock Filled Yes ❑ No Water Table Depth -----------—----------------------------------Rock Size ------------------------ bistance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____-_.-_-----_- •• ------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ______________________ Disposal Field (Specify Requireme ts) - -------------------- Dr existing and required addition reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accord sed agents signature certifies the following: once with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- "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 Californiad' Signed ------------------- --------------- ------ ----------------- -------- Owner - --By - - -- -- -------- -- e, ----------------------- Title (I other than ner) ----------------------------------------- OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --_ -__-__ _____--___ BUILDING PERMIT ISSUED DATE -- --`-- ----------------- -- - ---------------- ------- ---------------------------------------------------- - -----ADDITIONAL COMMENTS -- ----- -- ------------- ----- ---DATE --------------- - -------------------------------------------------------------------------------------------------------------- ------------------------------------------------- -----t -------------------------------------------------------------------------------------------------- ----------------------------------------- __ Final Ins ection b - ------- -- -------------------------------------------------------------------- -------- --- --------- - ---- -- - -------- - Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M