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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT z 3 Permit No. . (Complete in TriplicateL,- ------------------ --- ------------------------------------------------------- rr ------------------------_--------_---------------- 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 rdinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT10 ,�. lei- _ - --1 --------------------CENSUS TRACT --------------.----------- I 4 iY.i Owner's Name/ / •� r Address -_45R_4 _fcD------ -< =. Contractor's Name --------------------•------------------------------------------------------------------License #- w------:-------------- Phone --------------------------- Installation will serve: Residence f�artment House❑ Commercial:❑Trailer Court i❑ Motel ❑Other -------------- { Number of living units_____________ Number of.bedrooms =___Garbage Grinder 'Alorw Lot Size ____IscEe-er.c...4-__________-- ' ` Private � Water Supply: Public System and name --------------- ❑ , ----- --• -- ----------------------------------------------------•---•-- Character of soil to a depth of 3 feet: 5and�❑ �. Si1t� Cla.y',❑ Peat❑ Sandy Loam Cl y Loam I;-- Hardpan ;—Hardpan ❑ Adobe'❑ Fill Material _-_` _a. If yes, type ------------ --------------- p - (Plot plan, showing size of lot, location of system in relation to wells, buildings, a c`myst,be placed on reverse side.) 16NNEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- O Capacity Ty pe --------------- Material No. Compartments - Distance to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line ............. LEACHING LINE �[ J. E'rNo. of Lines --- -------------------'Length of eachline-.-----------------_-------- Total Length ,�---_ .......___....-------- TM^ s .fie. . yP € Depth Filter Material --;------ ------- --- 'D' Sox ____Viz=,-T e Filter, ------------------ - ?- . ----.._.....-•--..--.. Distance to nearest: Well --------------- Foundation ________________________ Property ILine _.___________---__. --. "SEEPAGE PIT.-. ] �.;- Depth-_-.;-___--.-_--- Diameter, � Number _._____._ -_- --��Rock Filled ,Yes [] No f0 "•� Water Table Depth ------------------------------------------------- Rock Size----------------- 4 t Distance to nearest: Well ___________________ _` _ '��_ _ ____Foundation,, --------------- Prop. Line ________.._-_ REPAIR./ADDITION(Prev. Sanitation Permit# _______-.___________________---_ E - ------------ Date - -- -----•---------=-------------} Septic Tank (Specify Requirements) -------------------------------------------;---------------=-- ---- —--------------- ------------------------ Dis sal .Field (Specify Requirement } ;' `��`� �� ------------ -- - �- -- -- - -- - ----------- ------------- ------ -� ------------------------- ----------------- ---- (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 he performance of the work for which this permit is issued, I shall not employ any person in such manner as to became s ct to or s Conhpensation laws of California." Signed 1....___ -_ - --- . ^ Owner By ------------------- - -----------------------------------:----------------------------- Title (Ifo than owner) . . s FOR DEPARTMENT USE ONLY �- APPLICATION ACCEPTED BY --- - - -- ----- - DATE -6 ---- ----- 'BUILDENGPERMIT ISSUED -------------------------------------- --------------------------------------------------------' -----DATE ------- -----•--------------•-------------- ADDITIONAL COMMENTS-=-- 4- - —------------------------------------------ - = - - - --------------------------------------------------------------------------------- ---------------------==-------------- ==------------------------------------------------------------------------- ---------------------------------------=''�' ri -Final Inspection by: - ,�- -- - -- -- - -- -- - Date _ _' _1. r: - - � , SAN JOAQUIN LOCAL HEALTH DISTRICT 004 E. H. 9 1-'68 Rev. 5M