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FOR OFFICE USE: f o APPLICATION FOR SANITATION PERMIT Permit No. ---------------------.4 0 (Complete in Triplicate) ---------=---------------------------------------------- ---------------------------- This Permit Expires ] Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: of ? ' r�; y; JOB ADDRESS/LOCATION --- __--- ..__CENSUS TRACT ---------------•-r;-1----!--.-- ,P - ...... Owner's Name _______ ------- ' Address ------ --------- ------------------!----------------------------. City --------------------------------- Contractor's Name .- f.!-)- ._r^t1-_ --- -E'-`n- -- --- = - _--------License # -- I _.� _ Phone f4 '_/!?! �1- -- r Installation will serve: ResidenceApartment House,F] Commerciaf ❑Trailer Court ;❑ a Motel ❑ Other -------------------------------------------- Number of living units:___ ----- Number of bedrooms -__...Garbage Grinder ------------ Lot Size ----,-- P 1 Water Supply: Public System and name -------- -' e -.- Private ❑ -------------------------------------:- Character of soil to a depth of 3 feet: Sand'❑ Sit 0- Clay El- Peat❑ Sandy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe X Fill Material ------------ If yes,type ----------------------------- (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:f ] „ Size------_----------------------------------------- Liquid Depth _______________-.- ------ Capacity -----------------•--f Type -------------------- Material------- ------ No. Compartments ---------------- Distance to nearest: Well -------- ---'---------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING ------•-- _--. ---LEACHING LINE [ ] No. of Lines ------------------------- Length .of,each line---------------------------- Total Length ----------- ---------------- R Type Filter Material _____________ Depth Filter Material __-________-_ 'D' Box ---- �- - -------De -------•------•-----•-•-------- Distance to nearest: Well ________________________ Foundation ------------------------ Property line :_:__.____.____::-_--_-- j SEEPAGE PIT Gil Depth ---- - -------- Diameter j ?____ Number ____;___.�__________ Rock Filled Yes No 0 - Water Table Depth �l---v--------•-----------•• Rock Size �= : .� + Distance to nearest: Well ---------e'1-G__t'1__12_......_Foundation ____, ------ Prop. Line ----- ------------- --- 1 - 'I REP- 0ADDITION(Prev. Sanitation Permit# ------------------------------------------ Date ------------ -------------------) Septic Tank )Specify Requirements) -------- .-------- - ------ --------------------- ------------- N------------------ - ----------- eyl r --------- Disposal Field (Specify Requirements) __________f U -- -------- :- �.- -- ---------------------- --------------------------------------------- -------------------------------------------- -- - ---------------------------------- ----------- -------------------------------------------------------------------------------- ---------------- - ------ - (Draw existing and required addition on reverse side) I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin k 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 - . �--:,-,ate- --- ,/. _r - � '[ /4 / " / t Title .... fii� '� f C --------------------- By ----- - -------- _ =l = f ------ - (If other than owner} - FOR .DEPART ENT USE ONLY APPLICATION ACCEPTED BY �i/w---------d---,S-I--Z---A-- -- ------------ -- --------------- DATE BUILDING PERMIT ISSUED -----..=. `-.------`--------------------- DATE ADDITIONAI, COMMENTS ---------- ---------------------•----------------------------------------------------------- ---- ------------------------------- -------------------------- -------------------------------------------------------------------------------------------------------------------------------------.-------------------------------------------- ----------------------- ----------------------------------------------------------------------•- -------------------------------------- -- - ' - _ - -- - - --- - ----'------'---------^-------------.------------------------------------- - - -- - -- iFinal Inspection by: f ------------------------------------------Date .'._ --. �---�-- - ------------ 5 N JOAQUIN LOCAL HEALTH ,DISTRICT E. H. 9 1-'68 Rev. 5M