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FOR OFFICE USE: r,F APPLICATION FOR SANITATION PERMIT ------------------- --------------------------- Permit No a (Complete in Triplicate) - �. ------------------------------------------------ ------- Date Issued ____________________________________ This Permit Expires 1 Year From Date Issued i i 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. JOB ADDRESS/LOCATI _ _ �p___.________ { - - --- -- - - .__CENSUS TRACT -------------------------- I Owner's Name _. _ ._ _____ _ _ _________ ____ _ I __ _ _____.________-. _ -__._____________-__Phone Address ------ City Contractor's Name ---- - -- - _GG!/11:.License #��` � Y Phone ------------------ .____.-_.._ Installation will serve: Residence Apartment House-E] Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units:------- Number of bedrooms - _____Garbage Grinder ------------ Lot Size _._Y3----fes_.-_5-nu-----________________ Water Supply: Public System and name ------ ----' ------------- - ----- -•- - ----- -------- ------------------ --------------------------Private ❑ Character of soil to a depth of 3 feet: Sand. 'El Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .T 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 seep ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[Pf _________________ Liquid Depth _0-------------_'___,____ Capacity __�_�- n_p. Type _ -a- Material _ __ _ No. Compartments .............. G' istance to nearest: Well ________j_p 6 -- -- ---------------Foundation ------)--F----------- Prop. Line ------- ----------- i LEACHING LINE [ No. of Lines ________ __._______ Length of each line______1.4_0_.,-__._.___ Total Length .___ gip_____________ f � 'D' Box -- 4-- Type,Filter Material _____�__ ____ Depth Filter 'Material ______1_ _______________________________ Distance 71.)-------- Ditrmre#er :�_Ifl_._ Number .----------�----------- - �earest: Well ------- _�Q_�_-____ Foundation -------I-V_ ___ Property Line. ____- _./ ---- Depth --- - __ Rack Filled, Yes No .0jj - Water Table Depth ` 4 Rock Size -I -'-------------- 1 Distance to nearest: Well_______________ __________________Foundation .__10.........--- Prop. Line ----------------------- REPAIR/ADDITION ________.______-____-REPAIR/ADDITION{Prev. Sanitation Permit# _______. ------- Date _________________________________-) Septic Tank (Specify Requirements) -------------------------------------------------------------------------------- Disposal Field (Specify Requirements) --------------------------------- - -------------------------------------------------------------------------------- ---•----------- 1 -------------- --------------------------------- ------------------------ ----------------- --- --------------------------------------------------------------------------- --------------------------- (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 the performance of the work for which this permit is issued, I shall not employ any person in such manner' 1 as toa me subject to Workman's Compensation laws of California." Signe - -- ------ ----- --------------------------------------------- Owner BY --------------------------------------- Title ----_:{�Q �G 'if ---- ---- ---- -------------------- {I other than caner) FOR DEPARTMENT USE ONLY T# F APPLICATION ACCEPTED BY ==--------------------------------------------- ----------------- DATE �� `1�--•------------------- 1 BUILDING PERMIT ISSUED ------------------------------------------------------------------------------- - ------ ------DATE -------------•----------------------------- ADDITIONAL COMMENTS - - ---- -- - ---------- ------- ----------------------- � - - --- -------------- --------------------------------------- - --------------- _= ---------- ' I ----------- ------------------------- _ ____ _ _ _1 --------__.___________- _____________.________-___-_______-______________-______________ __ Final Inspection bDate --- _../ � 19- - --- p Y '!' ,-------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M