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FOR OFFICE USE:. APPLICATION FOR SANITATION PERMIT 68—CIO" 5 Permit No. -- ----------------- -------------------------------------------------- ------ {Complete in Triplicate} ----------- ----------- ----------------------- Date Issued ---------------------------------------- This Permit Expires i 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. 549 and existing Rules.and Regulations: ---CENSUS TRACT --_-.-_----------------- JOB ADDRESS/LOC TI N . --- ' `f � Phone ------------------------------------ Owners 44 Jk Name ------ ----------------------------- '7 =-- ------------ Address ------------------ � ------ �---- - -- -- - ---- �- ---- i5 11 ---- ---- citY -----License # - -- -- Phone . Contractor's Name � Installation will serve. Residence Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other --------------------- Grbage Grinder _. _ Lot Size �'� --------- b f 'Vlg ' • Number of bedrooms Water Public and name ---------_••' ------------------- --- - -----------Private Fr i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E] Peat❑, Sandy Loam Clay Loam.E] Hardpan ❑ Adobe:E] Fill Material :L`'_'--_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 seepabe pit permitted if public/sewer i�available within 200 feet,) I PACKAGE TREATMENT [ I SEPTIC TANK'y Size_ l---X -- =------ - Liquid Depth -- -------------- Capacity A:�4z - Type Material--- 1fiments -- ----------- Foundation ± If--------- Prop. Line . -�--,---•--:------ Distance t- near t: Well --.-_�01 --- ----- p' LEACHING LINE [ No. of Lines -------)--------------- Length of each line------.-t V 4------------ Total Length --- -------- 'D' 'D' Box .-7YI!D--- Type Filter Material':--`-�-�--_ _a-__Depth Filter Material ------�-- ------------------! Distance to nearest: Well ---.--So.I---------- Foundation --- Property'-1-- -�`- --:- Property Line ------------------------ .14 ----- -� r A Depth �S - Digit �- � /D--- Number d ./ Rock Filled Yes '� No i❑ - -- ------ ------------- �. Water Table Depth ----------- - -------------------------------- Size _!3--- y------------- Distance to nearest: Well ----------- - P--------------------Foundation ----J f�__--- ---- Prop. Line -.-'S REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---------------- -----------------) Septic Tank {Specify Requirements) ----------------- m ---------" Disposal Field (Specify Requirements) ------------------- - --------- -------------- ------ ------------------------------------------------------- . � t ------------------- ------------------------ --------- _ - .._ ------- ----------------------------------- ---------------- . {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 --------- -- ----------------------------- Owner ----------------------- -- - ---- - ` --------------- Title ------------------- yA If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .....- __ - -- --------------- - ---- -------------- --------------------------------- - -----------� DATE ��=�_ - -� i BUILDING PERMIT ISSUED ------------------- ------- ------------- -----DATE --------------------------------------------- ADDITIONAL ------------------------------------ - - ADDITIONAL COMMENTS ---- --------------- ---------------- - = ------------------------------------------------- --------------------------------------------------------------------------------------- ------ -- ------- -' ---- ------------------------------------------------ ------------------------------------ - --------- - r"------ --- Final Inspection -- ----Date� - � �=---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H- 9 1-'68 Rev, 5M