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1 FOR OFFICE USE: APPLICATION fOR SANITATION PERMIT ------------------ ,,,. Permit No: . (Complete in Triplicate) - --------------------------- - ---------- Date Issued ---' ---------_-_-. ___ ThisL�ermit Expires 1 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/madee in compliance with County Ordinance No. 49 and existing Rules and Regulations: JOB ADDRESS/LOCATION .---(G_/- -_ _-- f�°�'--- r ..--------CENSUS TRACT -------------------------- Owner's Name C ' B ---------------------------Phone ------------------------------------ Address --- �� - Aa/ -- -- -- a'�"---------_. City ---------------- -----------------.-.------ Contractor's Name ---=-------- •---------------------------------------------------------=-------License # ---------:--------- ----- Phone ---------------------------•-- Installation will serve: Residence-�partrrientHouse❑-Commercial.❑Trailer Court l❑ !Motel ❑Other -------------------------------------------- Number ------------------------------------- ----Number of living units_____________ Number of b drooms ---___Garbage Grinder ------------ Lot Size ..-7J`f --��r ----------------- Water Supply: Public System and name --- W------------------------------------------------------ -------------------------- ------------------------- ---------------------------- ---------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i 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 pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK'f ] _ ._Size------------------------------------------------- Liquid Depth .-------------------,-•--- A! Capacity -----------------.--- Type --------------------- Material-------- ------------- No. Compartments ..----------- 1 Distance to nearest: Well __'---------------------------------Foundation _____-_________%_--Prop, Line ----- _--------_---- LEACHING LINE [ ] No, of Lines :- ------.---._ Length of each line---------=-- ------------- Total Length ----------- ---------------- 'D' Box .___._-.-__-•Type Filter Material ____________________Depth Filter Material --------------------.------------_1....... Distance to nearest:,Well------------------------- Founda#ion ------------------------ Property Line. ---------------------_-- "Diameter/ -------.-----------_-- ' • 5 .� R _ Rock Filled Yes r SEEPAGE PIT [ ] Depth -------------- Water ----------- -- --- Diameter ___-______-_-_-- Number --------------------- ❑ Na Ci Water Table Depth --------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well --------------------- ----------•------Foundation -------------------- Prop. Line -------_----- ------- REPAIR/ADDITION(Prev. Sanitation Permit# ___1'--- ---- -----------4r------------- Date ----------------------------- Septic Tank (Specify Requirements) -------- -"� - ----- ---------------------------------------------------------------------- Disposal Field (Speci y Requirements) _____ �-- ---- -« '-------- t E ` (� _ _ �- - lk} 4 s (Draw existing and required addition on reverse side) hereby certify that 1 have prepared this application and that'the work will be done in accordance with San Joaquin County Ordinances,..State Laws, and Rules and Regulations f. the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: v ` ` f 'I -certifithat in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Work n's Comp tion laws of California." Signed 1t '_`_-. `_-_-- Owner r BY ----------------------- ---------------- .............. -----------. Title - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 740-41--------------------------------------------- ------------------ DATE __- _�� 7 BUILDINGPERMIT ISSUED ------------=`---------------------- - ------------------------- ----------- ------------DATE ------------------------------------------ ADDITIONAL COMMENTS .--------------- -=----------------;---------------------------------------------------------------- -------------------------------------------------- --- ---- ------ ---- --------- ------------- ------------ ------------------------------------------------- -`', - -- - -------- ------------ ------------------------- ----- -- --- -- -------- ---------------------------------------- -- :------------------------- Final Inspection by Date ��_ �"�`�`"'. SAN JOAQUIN LOCAL HEALTH DISTRICT _ E. H. 9 1-'68 Rev. 5M r