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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No - -------------------------------------------------------- (Complete in Triplicate) Date Issued --- This Permit Expires 1 Year from 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'compliarice'with-County Ordinance No. 5A9 and existing Rules and Regulations/: JOB ADDRESS/LOCATION a�------PnO-FI�----` -------- ----------CENSUS TRACT _- ----a- --------------------------- • Owner's Name eN �-(CIBC ----_- -------Phone ------------------------------------ Cit --------------------- Contractor's #�l' Address o3_ - -/94�/-Tl-a--------t��_{-------------------------- --------- Y ------- r Contractor.'s Name �- '� ------------------------------------License - 9�- Phone : --------- -installation will serve: Residence ❑ Apartment House,❑yCommercial :E]Trailer Court F Motel ❑Other ----- ------------------------------------ t: Number of-living units:----- ---- Number of bedrooms ___-------Garbage Grinder ------------ Lot Size --_---------------------------------------- } Water Supply: Public System and name -------�_-_----_- __ ------------ ----------------------------------- Private F] i Character of soil to a depth of 3 feet: Sand',; Silt Clay ❑. .Peat❑! Sand_y Loam ❑.- Clay Loam❑_ • 4 IHardpan 0 Adobe ❑ Fill Material ------------ If yes,type ----_.___----------------- i ; {Plot plan, showing size of lot, locatiff system in relation to wells, buildings, etc. must be placed on reverse side.} on o NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC TANK'[ I 'Size-------- -------------------------------- - ----- Liquid Depth -------------------------- i Capacity ----------------- Type ------------ =------ ater,ial---------------------- .No. Compartments ---------------------- '. Distance to nearest: Well ------------- ----__Foundation --- ------------------ Prop. Line -------------=-------- LEAC i -- -- . HING LINE [ ]¢ No- of Lines ------------------------ Length;of ch cine------------__- -- -- ------ Total Length ----------------------------- ii D' Box i______._ Type Filter Material I -- ----_--------Depth Filter Material -------------------------------------- t __.____ -- �. S Distance to nearest: Well ---------------------- - Foundation ----------- ----------- Property Line ----------------_-•---- } SEEPAGE PIT [ ] Depth - -------------- Riameter _--_--- --- --- Number --------- - -- ------------ Rock filled Yes ❑ No Water Table Depth -----------Rock Size -- ----------------------------- i ----------------------------- ------ I foundatio ---- Prop. Line ---------------------- Distance - ti to nearest: Well --------------------- ' --- ] REPAIR/ADDITION]Prev. Sanitation Permit# --------.---- Date - =-- ---------------•--- • i Septic Tank (Specify Requirements) ------------------ ----------- ------------------ - -----------------;------------- ------ --------------- Disposal Field (S ecify Requirements) --------------------- -------------------- --------------------------/-----------.-------- t � - -- -- - — - = {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, 1 shall not employ any person in such manner as to become subject to Wor man's Compensation laws of California." Signed ------- - --------- --------- - Owner Title ------------ ------------------- -------------------------------------- BY ------- ---- (If other than owner) _ FOR .DEPARTMENT USE ONLY �- DATE - __ 71--------- APPLICATION ACCEPTED BY ----- -1--JA -------------- BUILDING PERMIT ISSUED ---------= ----DATE - ----------- -------------------- -------- _ 'M COMMENTS ---- - - - - -------------- ---------------- --- ------------------------------------------------------------------------------ - -- ----- ---- ------------------------------------------------------------------------------------- ----------- ------------ ------------------- -------- ---`----------------- ----------- ------ - - ------------------ ---------------------------------------------- ------ -------Date --t- ---- �r -- ------ Final Inspection a e -- ---- -- --- ------------------------------ f SAN JOAQUIN LOCAL HEALTH DISTRICT 4 E. H. 9 1-'6$ Rev. 5M