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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I ------------ --------------------------------- Permit No. E (Complete in Triplicate) -----------------------------------------7--------------- 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- - -- ------6t d/9-hrr-------------------------------------CENSUS TRACT --- - ------ Owner's Name __R P� +- j 6-e --------------- Phone _`. AddressCity P / �' G -- - ----------------- ---------------------- *�y Contractor's Name __.. (` _- _l __-____:____:________.License ��91-- Phone Fv� 76.5 Installation will serve: Residence ($Apartment.House,❑ Commercial:❑Trailer Court 1❑ Motel ❑ Other -------------------------------------------- Number of living units------t✓----- Number of bedrooms --____Garbage Grinder ------------ Lot Size __.________ WaterSupply: Public System and name ----_--------------------------------------------------------------------------------------------------------- Private Character of soil to a depth of 3 feet: Sand'Pfl Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe E] Fill Material ----- ------ If yes,,.t.ype,,._______,.---------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth --------------------------N f Capacity -------------------- Type -----------!i ------ Material-------------- ------- No. Compartments Distance to nearest: Well ____________ _____________________Found ion _______-_-__________ Prop. Line ________--______--- LEACHING LINE [ ] No. of Lines --- -------------------- Leng of each line_________ ___________.______ Total Length ____________________________ D' Box Type Filter Mate ral ______________-____Dep Filter Material --------------------________________________ ` Distance to nearest: Well __________ ____________ Foundatio _ Property Line _______.-__.____._._._ i SEEPAGE PIT [ ] depth -------------------- Diameter --_-------____-- Number ---_---------.--------___--- Rock Filled Yes ❑ No ❑ G Water Table Depth _____________ ------------------------------- ock Size -------------------------------- -` Distance to nearest: Well ____ ______________________________ __Foundation -------------------- Prop. Line ________.._________-_ REPAIR/ADDITION(Prev. Sanitation Permit# _______- _ _______________ __ Date __________________________________] Septic Tank (Specify Requirements) ------------------- ---- -------------------------------------------------------------- --------------------------- ------------ ------ ----------------- Disposal Field (Specify Requirements) ------------------------ ---------------------------------------- --------------------------------- --------------------------------------------------------- ------------------------------------- ------ (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 orkman's ompensation laws of California." Signed ----- - -- t - Owner BY a---- -------�------ Title --------- -------------- - -- -------- (If other than owner) FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY T.cA ----------------------------------------------------- --- DATE 1 "'��- BUILDINGPERMIT ISSUED -------------------------------------------------------- --------- -------DATE --------------------------------------- -- ADDITIONALCOMMENTS --------- - ------------------------------------ ---------------------------------------------------------------------------------- --------•------- --- --- -- - --- ----- - -------- -------- -- ---- -- ----------------------------------------------------------- -- --. --- ----------------------------Date ------------------------------------- ------------- ---------- - -- - -____ _ ------------- -- - - - ------ ---- ------------ ------------------------- --------------------------------- �- -- � --- --_ --- - ----- p Final Ins - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M