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FOR OFFICE USE: M APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Complete in Triplicate) Permit No. ______ -- 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 Ordinance No. 549 and existing Rules and Regulations. RegulationFss . JOB ADDRESS/LOCATION G --------- u - ------------- ----------- - CENSUS TRACT --57s 5 -Owner's Name ------- -------------->-------- ----------Phone Address �D------------- Contractor's Name __(Y_1�-- C.9/?0/ - -------------------------------------License #aV_3��e--- Phone _Pe_� a Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -----0A b---11}-11$-10-------- h Number of living units------------- Number of bedrooms ------------Garbage Grinder ___________ Lot Size .------ i---- --------------- I y Water Supply: Public System and name ---------- -------- --------------`-- ----------------------- ------------------------------------------------Private ❑ Character of soil to a depth of 3 feet. Sand'M Silt❑ Clay ❑ tPeafi❑ Sandy Loam •❑ Clay Loa m ❑- Hardpan ❑ Adobe ❑ Fill Material AIV---- If yes,type ---------------------------- (Plot ______________________ __(Plot plan, showing size of lot, location of system in rel 'on to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepa it permitted if public sewer is available within 200 feet,) (� PACKAGE TREATMENT { ] SEPTIC TANK Size_____ _]0-'-6__40-------------------------- Liquid Depth ___y -_-___,_ 1 72— Capacit .f Type _ Material__��i'► �lo. Compartments _ _._. _. ------- f . D' ante to nearest: Well ________b�-------------- ----Foundation�___�__�_. __.___ Prop. Line __�2 _'___._._._ LEACHING LINE No. of Lines _.___ ---------------- Length of each line-_-.--` -- Total Length __.__--_-___ - --------- 'D' Box ------------ Type Filter Material _____Depth Filter Material --_I --------------------------------- \ Distance to nearest: Well -h ---------- Foundation ------I+0----------- Property Line _L}___________________ SEEPAGE PIT [ ) Depth _ ------ Diameter ________________ Number ___ _____.____.__ Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------- --------Rock Size -------------------------------- \ Distance to nearest: Well ____-._________________________________Foundation -------------------- Prop. Line ...................... �. REPAIR/ADDITION(Prev. Sanitation Permit# --------_---------_------------------------- Date __-_________________________-__.__} Q SepticTank (Specify Requirements) -------- ---------- --------------------------------------------------------------------------------------- --t--------------------------1•---- Disposal Field (Specify Requirements) ---FOK----- ---- - =------er _--- -- --- 11 � -------------------------------------------------------------------- 1-_ -- -'---------------- -------------------------------------------------------------------------- - ------- (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 - -------- T G , = C• - --------------- Title (If other than owner} FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ -c� • ------------------------- ----------- ------ ----------- DATE ----------- BUILDING PERMIT ISSUED --------- ----------------------------=--------------DATE .._-_.---------------------- - - - ---------------------------------------------- - ------------ ADDITIONAL COMMENTS . ----------------------------------- -------------- --- --- ----- ------ - ----------- --------- -- ------ ----- --- ---- - ---- -------- -. - ----- --------------------------------------------- --- ---- - - Final Inspec ----- ------ - ---- --- - --- ------- ------` Date SAN JOAQU N LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M