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I � � FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT fPermit No. (Complete in Triplicate) --------- ---- -------------_ -_---_---------.---------__ This Permit Expires 1 Year From Date Issued 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 Ordin ce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - -- ---------CENSUS TRACT _______________ '. Owner's Name -------------------------------------------- Phone ------------------------- -- -- � i Address -��..�----� ��,Gt��' --------------------------- � � `` + _ cit .�� --��----- ��.�6�__ v Contractor's Name .__ -- ---- 6s4'=-, _- ------.License # - /� Phony _ - 4 � Installation will serve: Residence partment House❑ Commercial :❑Trailer Court 0 Motel ❑ Other -------------------------------------------- Number of living units:____ ____ Number of bedrooms .(____Garbage Grinder ------------ Lot Size --- 19 Water Supply: Public System and name � � -------- ` Private E] I` Character of soil to a,depth of 3 feet: Sand'[ Silt Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam '[] = t, tHardpan ❑ Adobe Fill Material ------------- If yes, type ___________________________ 9 (Plot plan, showing size of lot, location of system in relation to wells, buildings, .etc. must be placed on reverse side:-} 9 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'{ ] Size--------------------.--------------•------------ Liquid Depth ------------------------- Capacity -------------------- ------------------- -- Ca acit Type ____________________ Material---------------------- No. Compartments do vK Distance to nearest: Well ------------------------------Fo��ion---------- Total Leng h Lin •-___`_____...:.-� LEACHING LINE [ ] No. of Lines ----- _____;____-_ __ All ------------------------- Length of e9ch line._ _ __-__ `D' Box ��?_�____ Type Filter,Material4__�__�4-.�-_Depth Filter Material �c}�---------------------------- Distance - r �� i Distance to nearest: Well _�trfit�l----�r Foundation /A0---- Property Line -_�'�_______. SEEPAGE PIT [ ] Depth ----� _____ Diameter _ _----- Number __ ______�___�Rock Filled Yes No i� m Water Table Depth --------&47�---------------------------Rdck Size f �`¢------- tom_ Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line __.____---______-__-:_P REPAIR/ADDITION(Prev. Sanitation Permit K# -------------------------------------------- Date ----------------------------------11 Septic Tank (Specify Requirements) ------------------------I------ R -•-------- ------ ----------- 00 Disposal Field (Specify Requirements) ___ __ _ -------- __°_ 4 r1 --------- (D.3 5 ----------------------------------------------------------------------------------=--------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 'i I hereby certify that 1 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 i the performance of the work for which this permit is issued, I shall not employ any person in such manner as to bee* je -to m orkan's 6pensati.on laws of California." Signed ------ w G ------- Owner BY -- Title` ----------- -- -------- ---- ( othe an owner) j OR DoTMENT USE ONLY ' APPLICATION ACCEPTED BY -------- = --------= DATE = ` BUILDING PERMIT ISSUED --------------------------------------------------DATE --------------------------- /if'nNAL COMMENTS - - �� ------ - - --- ------------------------ ------- ---------------------------------------------------- ------ ---------- -- -- - ------------ - - -------- - - ------------------------------------------- ---------------------------------------- -- - - --- --- --------- -- ----------------------------------- -------------- --- --- - ---------------- FinalInspection by: __--- -- - --- -- - -- -- -------------------------------------------------------------------------------Date ------ -r �:/ ------------- AN J AQUIN LOCAL HEALTH DISTRICT I E. H. 9 1-'68 Rev. 5M