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FOR OFFICE USE: "'U" -' - APPLICATION FOR SANITATION PERMIT ------------------=--- -- Permit No. (Complete in Triplicate) ___________________ -- -------------------------------- 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: Y -/� JOB ADDRESS/LOCATION . , J- � /� ---------G --------------------CENSUS TRACT -------------------------- Owner's Nome ------------------------------------------------- ----------------Phone - ---------------------------- fcrr� ` Address / - ----------------- City ------------------------------------------------------- = Contractor's Name ._'` -------------------- -------- - -------- - - -'-------License # _/Z4.3. _Yt'hone ----- -------------------- Installation will serve: Residence [Apartment House❑ Commercial`❑Trailer Court ?❑ Motel ❑ Other -------------------------------------------- Number of living units:-------I---- Number of bedrooms _- -----Garbage Grinder . ------ Lot Size __ ------- ______ ____________ ' Water Supply: Public System and name ________________________ _Private 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, mustbe placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) j PACKAGE TREATMENT [ lk SEPTIC TANK [ l '_ _��t_�S----------- pp SizeLiquid Depth ---------------- Capacity l_ 4c Type F__�___ MaterialNo. Compartments 'a--------------- Q Distance to,nearest: Well ------5.6__'____________________Foundation __!__&-------------- Prop. Line ---- __'__.-____-__ LEACHING LINE No. of Lines s _--. -------------- Length of each lin e------APO-...... ------ Total Lengthy,-- - - --- -_--.-- 'D' Box _-- ----.__-- Type Filter Material -----. -- ----Depth, Filter Material ------1_g-J-------------------------- ---- Distance o nearest: Wella________ Foundation -----14------_------ Property Line --------------- SEEPAGE PIT [ Depth Diameter ___3.3_'/_ Number .........I------------------ Rock Filled Yes ffr' No i[] Water Table Depth ------------=-C6d__------------------------Rock Size ---- / --- ------- Distance to nearest: Well ------------16-d-_--_______________Foundation ----.,lG-----____ Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic ------------- ----_Septic Tank (Specify Requirements) --------------!-------------------------------------------------------------------------- ------------------------------ t DisposalField (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 Work 's Compensation laws of California." B - -------------- Owner Signed ----------------------- --- ------Y :-- ---. Title __..--� -- (If other than o f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY Z------ - ?.� 7 ---------------------------- DATE ---- ---•------- -- BUILDING PERMIT ISSUED ------------------- -------------------- DATE __..--------------------------------------- ADDITIONAL COMMENTS ----�---/11- 5---------- r --------------_------------------_____-___._____ ____________________„__-___.___________________-__________.._-_ ______.___________-.____.___-.._____._____________________ Final Inspection by ___ ____ -_ _ _ - _____ - = / Date __... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.