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F4&OFFICE Use: APPLICATION FOR SANITATION PERMIT '� Permit No: _._y1-____aS. [Complete in Triplicate) - - - ;ice'° -j-1, - _ „ 4 Date Issued --�-�5-:�L __.._______-______________ -------------- ---- This Permit Expires 1 Year From Date Issued Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: 1 JOB ADDRESS/LOCATION . - - Q------ / CENSUS TRACT Owner's Name -- _ .--ll-,e- ------ :---- -------- � Phone x Address -_.- ___ � City e ---- = l1------ ------ Contractor's Name _.__ __.___._G "�- -___.License #/-��3��__ Phone ________ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑Trailer Court ;[] Motel ❑ Other --------- ------------- Number of living units:---"___ Number of bedrooms ---- ----Garbage Grinder —_____ Lot Size ____________________________________________ j ' Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam.❑ Clay Loam .0 N Hardpan' Adobe ❑ Fill Material ------------ If yes, type ________-_____________ (Pilot 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 available within 200 feet,) 41 PACKAGE TREATMENT SEPTIC�TANK'E� a Size____________ ___ ______ _ _ Liquid Depth __ � _ _.. _______,____ Capacity � P Y F -Q- -- .-- Type __ Material_ - ___ No. Compartments �__________ ____ Distance to ne rM est: Well _____________5-----` �I ----------------Fourtdafiion -------�-�--`-------- Prop. Line ---�--:..:...----- -v LEACHING LINE M No, of Lines ------l----------------- Length of each line__.-__._,�__6__�__.____ Total Length _____Sd................ 'D' Box -=------- Type Filter Material ------Ss_-'----Depth Filter Material ---.[.g-----_____________________________ t Distance-to-nearest:-Well _____`se, I40 Foundation _t________________ Property L•ine,-_S_.�:.......... - SEEPAGE PIT [ Depth ...... S_-.__ Diameter ______ ------- Number --------------- __ � i❑ �j _/_______. Rock Filled Yes No Water Table Depth -------------Q_�-- ---------------------------Rock Size __�f=p-� `-r- ------------ r � Distance to nearest: Well ____--___--__)__0 d___________________Foundation --------- Prop. Line _._ -------._ _. __ q REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------- ----------- Date ----------------------------------1 SepticTank (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 "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 ------------ -- ------- -------------------------`-'C�`�- ------ ---- Title ----�'�(r:` r - ---------------- � (If other than owner) F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------ ------- -------------------------- DATE J" ----------------- BUILDING PERMIT ISSUED -------------------------------------------------------------------------------------------L--------------DATE -------------•----------------------------- ADDITIONALCOMMENTS ---- -------------- ----------------------------------- -------•------------------- -------------=--------------------•------- --------------------------- ---------- -------------------------•----------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- --------------------- -------------------------------------------- --------------------------------------- ---- ------------------ ---------------- ---------- --------------------•-------------- ------------------------------- -- v - / -� � -- - -=------- ----------------------------------- -------------- --- ---- --------------- Final Inspection by. z.l� ------------------------------------ ------------------------------Date -- ------- .>� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M