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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / ----------------- Permit (Complete in Triplicate) ` This Permit Expires 1 Year From Date Issued Date Issuedt-'0?7 '6/7 ---------------------- ---- ----------------------I 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/LOC ION -------------4 _a: _ x -------------------_-------- CENSUS TRACT .. Owner's Name =4 --Z=� -Phone c�r 4-- !�--------- I` �J I ----------- - Address ------ s ---- / - - %1 + Y City � Contractor's Name ----------- __40--- 1e7�----------------- -=-------.License Phone N1;:r__1Zi "- Installation will serve: Residence$Apartment HolCommercial ❑Trailer Court ,E]Motel F-1Other -----------------------------------------•-- f f Number of living units:____--__ Number of bedrooms .___.-_Garbage Grinder _ l - Lot Size __ ~.��---� ��------• --------------•--------Private, � Water Supply: Public System and name -- ______❑Silt Clay Peat ❑ Sandy Loam Clay Loam ;❑ Character of soil to a depth of 3 feet. Sa d ❑ Y ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ (Plot plan, showing size oil lot, location.of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (Noll septic tank or seepage pit permitted if public sewer is available within 200 feet,} `f . PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ----------------•---------- Capacity --,----- Ca:acit Type -------------------- Material---------------------- No. Compartments ------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------....... LEACHING LINE [ ] No�! of Lines - ---------------- ------ Length of each fine---------------------------- Total Length ----------- --------- ------ - 'D' lBox ------------ Type Filter Material --------------------Depth Filter Material --------------------•-----•----------- -_- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----___----. ----=---- ' : 7 " SEEPAGE PIT [ ] Depth -------------- "_--- Diameter ---------,------ Number -------------------_ -- __ Rock Filled Yes � No Water Table Depth ---------------------- - -___------" Rock Size ---------- ------------- -- Distance to nearest: Well --------------------------------- ------Foundation -------------------- Prop. Line -------------•-•------ IM: REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic Tank {Specify Reg it irements) -------- Disposal Field (Specify Requirements) ___ __ �------ �� --------C �; �'�------ �I ------------------------------------------------------------------ ---------------- -------------------II-------------------------------- ---------------------------------- ------------------II----------------- -------------- --------------------- -----------------------------------------------------------------------------------=------------------------------------------------------------------------------- '' (Draw existing and required addition on reverse side) I hereby certify that I have lprepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Lpaws, 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 B --------- � I L ----------------------------------------- Title ------� Y ---------------- other that nerl II FOR .DEPARTMENT USE ONLY ,M ' APPLICATION ACCEPTED BY _ _ _ -_-` DATE c _ - �----- --•->---------------- --- ---- ---- ---------------------------------------------- BUILDINGPERMIT ISSUED"------- ---------------------------------------- --------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS Y------------------------------------------- -------------------------------------------------------------------------------------=--- ----•-•---------------- - '1 ------- ------- - --- --- - ------- ----------------------------------------------------- --------- ---------------- - ---- ----- -- - ---------------------- -------- ---------- -- ---------------------- : ----Date ------- -- Final InspectionbSAN JOAQUIN LOCAL HEALTH DISTRICT k E. H. 9 1-'68 Rev. 5M.1