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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ' ,�,, "_ ,� s^,'t—`1 . , 4 • pe&mit No. .. f ------------------------- ------------------ , (Complete in Tripl'sate) . " f Date Issued --------- ------ -------------------------- = = � This Permit•Expires 1 Year From Date Issued -------------------------------------------- - Application is hereby made to the-Son 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. 5.49 a-d existing Rules and Regulations: t } CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION I ----------- Owner's Name -- ` -------------------Phon ;V - ------------- # r s v.. ---- Address _ I-------------------------•--- City .- Tlt�7.� 1 ■ �`- ---= � ------ ------- -------�-------- ---------- ---=---w icense# .�_�_�,_��--- Phone �.�---- Contractor's Name .�I� S �- -■S' 1 installation will serve: Residence [PApartment House❑ CommerciaOTrailer Court [I 1 Motel ❑ Other - ------------------------------------------ `- z �1 1 p Number of living units:.__ Number of bedrooms--__2_---Garbage Grinder __�t1�i__ Lot Size ___R- ---- - - -------.-- i 1e'', e r ! Private Water Supply: Public System and name .- --------------- ------ ---------------------------------------- Character of soil to a Idepth of 3 feet: Sand'] Silt❑y Clay E] Peat El Sandy Loam El Gay Loam :❑ Hardpan.❑ Adobe R'Fil[ Material 771.__.___ If yes,type ------ - - ------ - � 5 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Nonseptic tank or seepage pit permitted if'public sewer--is.available within 200 feet,) I PACKAGE TREATMENT ( ] SEPTIC ANK I[ ] Size-----------------------------------7! 1- -------- Liquid Depth --------------------------- --- -------------------:----- � + I Material------------------ -- No. Compartments --------- Capacity..- -_------ =---- - - Type ------ '` Distarice to nearest: Well ------------------------------------Foundation !--------------------- Prop. Line ------------•--------- 'Al f # Tota! Length :--------- LEACHIIVG.L`INE j ] . No. of Lines`_---- `------------- Length of each ine-------------------t-- --- `DBox ------------ Type Filter Material --------------------Depth titer'g Material -------------------------------------------- " Distance to nearest: Well ---- ------------------- Foundation ----- ------€- -------- Property Line -------------------- -- _ SEEPAGE PIT [.] Depth --- ---- ----------- Diameter ---------------- Number .--------°------------ Rock Filled Yes ❑ No i❑ Water Table Depth - ---- Rock Size --- } -- Pro Line r Distance to nearest: Well ----------------------------------------Foundation P REPAIR/ADDITION(Prev. Sanitation Permit# -------------------- Date -------------- ---I ------------ ) a. - ------------ 'F Septic Tank (Specify Requirements) ----- ----------------------------------------------------------- Disposal Field (Specify Requirements} -----1//0---- ------- --------------------------------------------------------- --- -------------------- ------------------------------------- i _ 9 (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 `r County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local"Health District. Home owner or licen- sed agents signature certifies the falilowiing: .». -� -- "I certify that in the performance of the work for which this permit is issued, I shall not employ any person. in sucfi manner as to becom subiect to Wo jcman's Compensation laws of California." Signed _ �- - --------------- ------------------------------- Owner ----- - -----------------------I--------------------- Title ---- ---- --------- - - - ------------------------------- I (If other'than owner) FOR DEPA1tTMENT USE ONLY APPLICATION ACCEPTED BY _____------ '---- ------- --------------- DATE 27 -- --------------------- BUILDING PERMIT ISSUED ----------•----------=`--------DATE ----- ------------------------------------- ----------- ------------------- --------------- ADDITIONAL COMMENTS ---------------------------------- ---------------- ----- ------ J b - ---------- -------- ---- - - ----------- - --- -------- ----------- ------------------------------ ------------- ----------------- ---- ------ ----------- ---- ----- -- ----------- -------------- Final Inspection by: --- ----- --- ---- -- "LC-- ---- --------- Date _ .T cl eSAN JOAQUIN LOCAL HEALTH DISTRICT ( E. H. 9 1-'68 Rev. 5M