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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ C/ -------- ------------------------ Permit No. (Complete in Triplicate) ----------------------=---------------------- p. --`------------• -------- --------------------------------- -------------_-_ 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: JOB ADDRESS/LOCATION .- - - ------J�_/ ------1 -----------------------------CENSUS TRACT ...... --��J--- Owner's Name ----/ 12------- _�_� �-�g �Y --------------------------------------------------°--------: Phone --�g� 7�' Q- ---- + Address __�_�_� �?� _ Vv_ }_lJ_/V e_�---- City r` qa I �" �`� r/` ------------------- Installation License #rr� c 9� __ Phone F� Contractor's Name -----.0 ------- ------------------- Installation will serve: Residence fit] Apartment House-7 Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- ; Number of living units-------I-__ Number of bedrooms ______Garbage Grinder ------------ Lot Size _A0 -G----•------- Water Supply: Public System and name --------------- ---------------•-•----------------------------------------------------- ----------------------Private R Character of soil to a depth of 3 feet: Sand F Silt❑ Clay ❑ Peat❑ SandY-Loam ❑ = CY..a Loam;❑ Hardpan ❑ Adobe-EDFill MaterialA/D----Il 1!D-___ If yes, type -__________________________ r (Piot plan, showing size of lot, location of system i relation to wells, buildings, etc. must be placed on reverse side.) oQ NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK' Size._______-_ ` �L �---��''�----- --- -/7-01-------- Liquid Depth ...�$----------•--- Cap lty --/> Q---- Type ✓Material_C� o. Compartments --t2---------------- istance to nearest: Well ------ ---------------------Foundation ___�-0------------ Prop. Line ---t�--....-........ . LEACHING LINE No, of Lines _______ _.________ Length of each line.-.2-6 ------------ Total Length /�?__________________ 'D' Box ----- ------ Type Filter Material la_0�_Depth Filter Material _-/57__________________________________ Distance to nearest: Well , +f ......... Foundation --------- Property Line _4-------------_--- SEEPAGE ____________________ SEEPAGE PIT [ ] Depth ------------ -------- Diameter ________________ Number ______________._____---_____ Rock Filled Yes ❑ No Water. Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------..-------------- REPAIR/ADDITION(Prev.'Sanitation Permit,# -------------------------------------------- Date ------------------..--------------) Septic Tank (Specify Requirements) ---------------- -- -----------------------------------------------------•---- --------------------------- Disposal Field {Specify Requirements) -------------- ----------------------------------------------------:------------------------------------------------ --------------- 4 ----__------_-----------__---------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------______________________________________________________________________________________________ (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 w ------------ --------------------------- ---- ---------------- Title ----------- -------------------------------------- -------------------- (If other than owner) �.-�-; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1 ��-------------------------------------- -----. DATE ---- --------------- -7 .. BUILDINGPERMIT ISSUED ------------- --------------------------------------------------------------------------------------------DATE -- ---------------------- ---------------- ADDITIONALCOMMENTS ----------- ------------------------------------------------------------=----------------=--° -------------------------------------- ------------- --------- ------------------ ---- -- `- ----- -------------- --------------_--=------- --- -------------- ------------------------- ------------------ - --- ---- ------------------------- --------------------------------------------------------------- --- ------------- ----- - --- - ------ ------- � --- - - -------- - -- - Final Inspection - -----------------------Date ----------- ----- SAN - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �/