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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -- ------ ------ ------ - - --- - ---- (Complete in Triplicate) , ---------------- ------------------- Date Issued _`�"=-��'- -- _ This Permit Expires 1 Year Frown Date issued cal Health District for a permit to construct and install the arlc herein r Application is hereby made to the San Joaquin Lounty Ordinance No. 549 and existingRules and Regulations- described. e ulations:described. This application is made in compliance with Cok CENSUS TRACT ----------- ---------- JOB ADDRESS/LOCATION - �` Owner's Name ---�/ -------- ------------------------------ Cit ------------------------------------------ --- ----3---------------- r - ---------- ---------- ---- v Address --- ----�r'� -- _ - ------License # .� �`- -- ------- hone --- ------ --------- - Contractor's Name ..__ .-_ .- - ------ --�--- lnstallation will serve: Residence Apartment House❑ Commercial ❑Trader Court ;❑ Motel ❑ Other ---------------------------------------- -- ----------- - Number of living units:----- Number of bedrooms T--------Garbage Grinder ------------ Lot Size -Z ---------Private Water Supply: Public System and name ----------------- ------- -----•------------------------ -- Character of soil to a depth of 3 feet: Sand'D Silt❑ Clay 11Peat❑ Sandy Loam Clay Loam El Hardpan ❑ Adobe E] Fill Material ------ if yes,type --------------------- ` buildings, etc. must be placed on reverse side.) {Plot plan, showing size of lot, location of system in relation to wells, sewer is available within 200 feet,} e it permitted if p 4? NEW INSTALLATION: (No septic tank or seep g p P SEPTIC TANK: Size_ . 1p-XI- --- -------- ---------- Liquid Depth _- PACKAGE TREATMENT [ ] . \ Capacity. _�tqB O Type --- Material -------------------' No. Compartments ---------------•-- i � � ------•Foundation ---IP------------ Prop. Line ----`��-�---�---------- r� Distance to neares . Well --------------` r1---- -.7 P� LEACHING LINE [ I No. of Lines �------------- Length of each line__.___..__-g3-------- Total Length :___.-.... ! •D' Box -Y-------- Type Filter Material ----- -IR-------- Filter Material ------ ------- ------------ t Distance to nearest: Well So--' - --- Foundation ------i-0-!--------- Property Line. _� i------------------ fD SEEPAGE PIT epth -------------------- Diameter '-------------- Number ---------------------------- Rock Filled Yes C] No C] [ ] ---�— = ` ----Rock Size ------------------------ - Water Table Depth ------- ----------------- ---------_---------- j Foundation -------------------- Prop. Line ------------------ Distance to nearest: Well ----------------------------------------- Date ------------------------------ REPAIR/ADDITION(Prev. Sanitation Permit ---•--- ----------------------- Date ------------------------------ 1 -, Septic Tank (Specify Requirements) ..._:_------------- ----------------------.----------- Disposal Field (Specify Requirements) -------------------------------= ------------------------------------- -------------- --------------------- ----1--- ---w ------------------------------ --------------- ------------- -------- ---- -- - - - - ' (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 certify that in the performance of the work for which this permit is issued, f shall not employ any person in such manner as to becomebl ct 10 Workman's Compensation laws of California." Signed - -- ------ - -------------------------- Owner ---- jitle -;�o - - - ------- By ------- -------- -- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -.- - ------ -�- --------•---- ------- ------- --------- -------- --. DATE .�_./.� :._-�........ �' ----------------- /, - --- -- - - -DATE ---- ------------------------------------- BUILDING -------------- --- -- -------------- -- ------------------------- --------------- -- - BUILDING PERMIT ISSUED ---------------------------------------------- -- ------------- ADDITIONALCOMMENTS ---------- --------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------------------------- 1 - --- ----------------------- ----------------------------------------------------Date � U -- - Final Inspection by/. - - --------- - ------- -------------- --- ------------------------------------ - -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.