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FOR OFFICE USE: ��A- �do c► �-'�'� �"�� I APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _-_-- ----- -_-. ------------ r __----_ e_----------------- --9l --_____--__._-- This Permit Expires 1 Year From Date' `Issued Date Issued _f' i. Application isrhereby 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 �/J----'9'L.='----------------------------------CENSUS TRACT --------------•----------- Owner's Name ---------------- - - _ — ------- ---------------------- ------- --- - ----- - Phone Z Pho Address 0A ' = � - city - Contractor's Name ------- -----f----- ------ -=- -- -0---`.--�- - License # - Phone ��y �� pi Installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court ❑ , Motel ❑ Otheri------------------------------------- r Number of living units:--- ------ Number of bedrooms ____-_.Garbage Grinder ------------ Lot Size .'.=f__4' '- __-------------I-- � Water Supply: Public System and name ------------ ---------- --------------------------------------------------------------- Private ❑ t Character of soil to a depth of 3 feet: , Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ' Clay Loam :❑ Hardpan Adobe Fill Material `�-�—If es,t e ___ .___-____.___.____ P ❑ Y _. yP I (Pl'ot 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.availabie within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------------- ------------- Liquid Depth __._____:-____-_____-___ Capacity _ Type ___________________ Material-------------_ ------- No. Compartments ____..__-_:____-__.__ `R Distance to nearest: Well _____________.________-_________Foundation _*__________________ Prop. Line -------------.-.______ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------------ _______�____- Total Length ____..___- ___________ �. _ �1 i 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -__-______-_.___________________--_.---_._ Distance to n6dr—tiW611`"` "_-----"_------ "•FouKddtion`-" ------------- Prope"rty Line'-_~-~ -_______________ 4 SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ,0 Water Table Depth "�_ _____________Rock Size -_________________-____________ Distance to nearest: Well ._____________________________________Foundation�----_____:_-__.---- Prop. Line ---------------------- t t REPAIR/ADDITION(Prev. Sanitation Permit# __-___ 7l____ __,-_ j_ �_/_�.____----- ___ Date _____________________ �_-__j_-_=) ` Septic Tank (Specify Requirements) -------------c G'"'r?-_---G-''�` "c.=t�-- ------- -------- ,�. - --------------------------•- Disposal Field (Specify Requirements) t` .-C =' ---------J------------ -------------- --------------------------------------------------------------------------- �--Iy�---xl d-- ......-------- - - -----------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------- (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 I Cunty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- se7 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 ------------- -----------------------I------ Owner �__ - - - - B �.__. . . -- Y -- - - --------- - --�- -- --- -- - '---- -------------------------------- Title -- - -----------------'- (If er than owner) r FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ________ s_-_ __ ____ -- --------------- ----------------------------------------------. DATE -----1 ------- BUILDINGPERMIT ISSUED ------ ------------------ -----------------------------------------------------------------------------.-DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------- ----------------------------------------------------------------- -------------------------- ---------------=------------------------= ------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -- , - - - ----------------------- ------------------------------------------ ------ - Final Ins ection b -------------- -- ---- - - ------------------Date ---` -1-` P Y: ------------ ------ y SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M