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t FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------- --------------------- Permit No. (Complete in Triplicate) -------------_------------ -------------- This Permit Expires T Year From Date Issued 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: JOB ADDRESSAOC N . p- /Lli..e--- ---t -------- ----------CENSUS TRACT --------------...-.-•----- Owner's Name _ . -- -------- fir } ----------------------------------------- ---------------- one ------------------------------------- Address - =------------------- ------ s Z17Address ,-r�, - _ 17 ------- - Cit ' ° . � --------- - -- - ••------------ in F Contractor's Name ------ ------------------ - ------------------ ----------------..- -License #� y Pone Installation will serve: Residence �rtment House[] Commercial ❑Trailer Court ;❑ Motel ❑Other ----------------________ i Number of living units:_____ _----- Number of bedrooms ____ Garbage Grinder ------------ Lot Size _______________________________-_-.____-__- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ .Peat❑ Sandy Loam -Clay,i.oam - __ Hardpan-[��-Adobe'[ -?-Fill Material_=-�===.-1f-yes,type _.:--=---'--------.` ---- - (Plot plan, showing size of lot location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1\V NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q , PACKAGE TREATMENT f I SEPTIC TANK[ Size_- '__ ------------------- Liquid Depth __'----_______________________ Capacity _ ! ooType MateralNo. Compartments -__________ J _ v 11 Distance to nearest: Well- yl_t7,a3_�___________________Foundation _.._/p____________ Prop. Line - ---------- LEACHING ____.-:LEACHING LINE (PI No of Lines___�'.'-------- - -Length of each line- -IAV..___.__.__ Total Length .-_•._________-. 'D' Box ---- Type Filter Material _42-L-------- Filter Material --------- ___________________________ Distance to-nearest;--Well -Foundation t??_'=------- Property Line. __4------------------ [h"I Depth ------I f------ ter _�`Z0_---- Number ----------2------------- Rock Filled Yes No i❑ -WaterTable Depth------------- H� :3� -----------------=-----------------Rock Size ��,�----------'�---------- Distance to nearest: Well -------------tP-n -----------------Foundation ____1 ----------- Prop. Line -----S__-.-...__.._. REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date -_-----------_--------------------} SepticTank (Specify Requirements) - ---- - ----------------------------------------------------------•---------------------------,:---------------------------- Disposal Field (Specify._Requirements)...-__-----A_!--- - ----------------------------------------------------------- ----------------------------------------------------- ----------------------- - _� •- --_� (Draw existing,and•.required addition on reverse side) I hereby certify that tl have-prepared`this-•application-and that the work will be done in accordance with San Joaquin County Ordinances, State.Laws,l-and._Rules_arid,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 as to become subject to Workman's Compensation laws of California." Signed --- ------- Owner - �j - --- TitIe _.. '------------ ----------------- BY ------- -- -- - - ---------------`l ----------- (If ofiher than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --------- ------- ----------- -----•--- ------------- ----------------------- DATE 1 . ----- ------------------- BUILDING PERMIT ISSUED ------------------------- ------------------------------------------------ -------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- ----------•---------------. I ---------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------•---- --- ----- ------------------- -------------- ----------------- =---------------------- ------------- ---------------------------- ------------------------------------------------------------------- - - ---- -- -------- ------------------- ---------- ---------- -- -------------- ---------- --------------------------------------------------- ------ - Final Inspection by: - -- -- -- -- ----------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT ``E. H. 9 1-'68 Rev. 5M.