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a FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . _ Permit No. (Complete in Triplicate) / -------------------- Date Issued This Permit Expires 1 Year From Date Issued ' --------------------------------------------------------- �5 Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..__- 59.!7--f---- - CENSUS TRACT _ ��--•• /} ---Phone Owner's Name .---__L:.----- ------------------------------------------ �.--- ---------• Cit -------------------------------------------- Address -------- ." - --------- -------] ----------- Contractor's Name .------ — ---License # Phone ------------------••-----...__ Installation will serve: Residence A artment Hous F-1 Commercial ❑Trailer Court i❑ Motel ❑Other(-'------------------------------------------ 1 i Number of living units ----- Number of bedrooms -.3.__--_Garbage Grinder --- -------- Lot ize --------------------------------- ---------- a i ----Private Water Supply: Public System and name ------------------------- --------------- -n ---- " lay - Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ 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 Lpit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------- ------------------------------------- Liquid Depth -------------------------- Capacity --- ----------------- Type -------------------- Material--------------------- No. Compartments Distance to nearest: Well ___________________________________ Foundation - Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines -------j--------------- Length of each line-------- -------- ---.- ------ Total Length --------------------- --, 'D' Box .----_------ Type Filter.Materiai .---.-------•--------Depth Filter Materia] ------------------------------------------ Distance to nearest: Well _----------------------- Foundation Property Line. ------------------------ SEEPAGE PIT Depth - Diameter j---------------- Number -.-------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ---- ----- I Foundation Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- --------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ---------------------------., . --------------------------------------------:..------------ 10, Disposal Field (Specify Requirements) -..6L-d4-1_Z ------------ -- ---------------------------------- ---- f --------------------- ------ --------------------- (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 Mules and Regulations of the San Joaquin Local health District. Home owner or licen- sed agents signature certifies the following: - T "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 Workman's Compensation laws of California." Signed 1------------- -' Owner w �' -------- --------------- t ------ (If (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ---r..- DATE ---------- 3---- ------------ ----- BUILDING - - ------------------------------------------------------------------------------ APPLICATION PERMIT ISSUED ---------------------- -- - ---------"- - -----DATE ------------- -------------------- - ADDITIONAL COMMENTS ..----..."----- -- """"----"" - -- --- -------- ------------------------------- k -- --------- ------------------------------------------------------------------------------------------------------------�__----_______-_--____ 70 Final Inspection by: -----------------Date ------ --- - - ------- -----•---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-`b8 Rev. 5M