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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ----------- ---- -------------- ----- (Complete in Triplicate) ------------------------------------------ ---------=----- Date issued _44'��- This Permit Expires 1 Year From 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. 5 49 and existing Rules and Regulations: JOB ADDRESS/LO ION .__Q___- 1- -----4----------- ll�I!_ I7��-- ------------------------CENSUS TRACT --------- -y - /� ----PhoneK% Owner's Name ._./4--�------ �__ _ : _ T AN- -------- i Address 4 , � City - -- -- - --- / I G Contractor's Name ------- --- -- - � ,- 5— License # C � Phone � `G ) Installation will serve: Residence [�Apai�trfient House❑ Commercial[Trailer Court ',❑ Motel ❑Other ----------------- --------------------- Number of living units:_.----__.__ Number of bedrooms YZ-__-__Garbage Grinder ___-___.--__ Lot Size __ _ �'ej Water Supply: Public System and name ------------------- - -- ---------------------Private'sa Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe ❑ 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,) �U i PACKAGE TREATMENT [ ] [ ] Liquid Depth ____- \ SEPTIC TANK Size --- q p IN. Capacity -------------------- Type ------------------------- Material---------------------- No. Compartments ----------------• - Distance to nearest: Well ------------------------------------Foundation --------- ------------ Prop. Line ---------- ---•----- Of Length of each line------- ------------ Total Length ------ --=---- •- LEACHING LINE [ ] No. of Lines ___.-___-�------------ ---- 7 ----------- --------------------- V Box ___-____.__ Type Filter Materia t__C?L'-�-_Depth Filter Material ____ __ lD---- ------ Property Line 6 -------------- Distance to nearest: Well _._ __ _________ Foundation ______ _____ Depth ---------- Diameter --------------- Number ----------------------- Rock Filled Yes ❑ No SEEPAGE PIT [ 1 P -------- WaterTable Depth ------ -----------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------...-. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------------- ------- Septic Tank (Specify Requirements) ---------- - -------------------------------------------- ------------------ ---:------------ �' G _ --tL_ /AGr ---------4AI------. Disposal Field (Specify Requirements) --- --- --- --- 5A ------------------ -- --------------------------- - (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: or which thus permit is issued, I shall not employ any person. in such manner "I certify that in the performance of the work f as to become subject to Wo man's Compensation laws of California." " = Owner Signed - - -- -^---�- --- -- ------- ----------- ------- - �c /+ ------- ----------- ------- ------------ C J. _ 1iC ----------------- -------- ----- title (If other than owner) FOR DEPARTMENT USE ONLY � DATE --- --~-- ----`-� ----------- _-- -- �----- APPLICATION ACCEPTED BY ---__ -f-�` -� ---------- -- BUILDING PERMIT ISSUED --------------------------------------------- -------------------------------- - DATE --- ----------•--- ----- ------------------- j ADDITIO`NAL COMMENTS ------------ ------------------- ------ --- -- -------- ----------------------------------------------------- ------------------ --------------------- - -- - - --- -- ----r- -- - ------ --------------------------------------------------- --------------- _ ----------------------------------------- ae c ----- Final InspeeSAN JOAQUIN i LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M