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FOR OFFICE USE: _ Ad APPLICATION FOR SANITATION PERMIT ---- -------- -------------- (Complete in Triplicate) Permit No: ------------------------------------------_____________ This Permit Expires 1 Year From Date Issued Date Issued 1 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: ____________________CENSUS TRACT JOB ADDRESS/LOCATION � = ---------------------------- - -Owner's Name ---------- ------ - ------------------------------------------------ -------Phone ------------------------------------ -- ----- U) VAk Address - -- -Y city "0 -1---------------------------------------------------------- ---------- --- o Contractor's Name ----------- - 7 rrL 4_._--,____.License ----# 4 _ Z---- Phone ------------------------_--- Installation will serve: Reside ce ( Alpartment Nouse I�I Commercial L�Trailer Court F-1 1r151ultulivil VVIII JGIYG: .... .. LI - Motel ❑Other -------- -------------- --------------- �+ r } �....�......• ..r i�..•.y ..••'- 1S�IIIS..cr v4 �ca�rVVrn'a ------------�7UTbQgE VT1S'�17sf" Water Supply: Public System and name ------------f---------I----------- - --------------------------------------------------•------------------Private (� Character of soil•to a depth of 3 feet: Sand❑, SiltfD Clay ❑, Peat❑ Sandy Loam { Clay Loam Ej 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 see age pit permitted if ublic sewer is av able within 200 feet,) PACKAGE TREATMENT SEPTIC TANK Size--'___" r t �____ Liquid Depth _____ _'______________ 1i Capacity -�____:�_ _�Type - -- ` lc ---- Materia ._ - No. Compartments ----- ----._-:__-- Distance to near t. Well ----------- __________________Foundation ------/-Q_-__-_____ Prop. Line ------15-______ LEACHING LINENo, of Lines [ ......... ..----____-- Length of each line------75---------------- Total Length ------ -------- 'D' Box ------I----- Type Filter Material ----_-�__R__Depth Filter Material -------------J__4__--__---___-_____-.__..- t Qista �I r nce to nearest: Well ___._------ '------____ Foundation _----1_V------------- Property Line ____________________ � � Depth ----10- _______ Number --.__- _______________ Rock Filled Yes Qr No i❑ _ �_-�_�� - Water Table Depth ------------- __c$--------------------------- Size --------E1-------------------- Dista ---X----------- c � Distance to nearest: Well -------------so-__`----_............Foundation _-__ ------- Prop. Line ----- .___.____.-__ REPAIR/ADDITION(Prev. Sanitation Permit 5/# --------------------------------------------- Date ---------------------------------- Septic ______________________ _ __Septic Tank (Specify Requirements) -------------------------------------------------------------------------- --------I----------------------------. --------------------------- . DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------ ------ - - - -------------------------------------------------- ----------- ----•----- -------•----- ---------------------------------I------------------ ------------------- -----------------------------------------------------------------------------------------------------•------------- (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: "1 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 ---------- ----- P--- ---' ------- = ------------------- Owner^ n BY --------- Title ---,-f c Y - w __ (If other than owner) I FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'--- ` =------------------------------------------------------- --------------------- DATE _-,f -. -,�------------- BUILDING PERMIT ISSUED ------------------------------------------------------------------ - --------------------- -------DATE -- --------------------------------------- ADDITIONAL COMMENTS __`------------------------ --------- ------------ ----- -- ------- ------------------------------- - - ---==--------- - ------- - - - - - ------------------------------ ----- --------- ---- -- ----- -------- ----------- --- ------------ Final Inspection by: - / _ ' ----------------------------------------.Date --- -2 -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ,E. H. 9 1-'68 Rev. 5M �-