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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT " F ''4 Permit No. _-�J (Complete in Triplicate) ________.___ This Permit Expires l Year From Date issued Date Issued _1 _____ _r___.. 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION --- ------ ------------------r a y ---- Xl:�--------------CENSUS TRACT _�-g- M Z�of-L3 Owner's Name -l ----- 1%� ----------------------------------- -------Phone --- Address --------- --------A_$y----------ZAfl41l/�Sd? City r��_ i t> Contractor's Name ------, - -.-_____ -------------------------------------License # Phone Z>V_3 Zf- Installation will serve: Residence U Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ------------------------------------------ Number of living units:_..__ ----- Number of bedrooms ______Garbage Grinder ___.____._ Jot Size ____ - "___:—_______________ _ Water Supply: Public System and name -----------------,jam- s( -----------------Private ❑ Character of soil to a depth of 3 feet: Sand'] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [:]Hardpan E] Adobe E] 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 [ ] SEPTIC TANK:[ ] Size. ___________ Liquid Depth �1......J_....... Capacity =/ ___-- Type'pf4` '©_1�Material--------------- --'-- No. Compartments ------a ........... Distance to nearest: Well ____________________________________Foundation __1[?_------------ Prop. Line -------.�z------------ LEACHING LINE [ ] No. of Lines -------3----------- Length of each line.___-,.G__ ------------ Total Length ............. J 'D' Box ----/------ Type Filter Material 6x,�Depth Filter Material ___/ __-----__________________________ Distance to nearest: Well ___6------------------- Foundation ___/0------------- Property Line __._5--_--__--__---_ SEEPAGE PIT [ ] Depth ____________________ Diameter _______________ Number --- ------------------ Rock Filled Yes E] No Water Table Depth -----------------------------•- -------- --Rock Size -- ------------ ----------------- i Distance to nearest: Well ------------------------------------------ Foundation ----------------•--- Prop. Line ---------------------- O REPAIR/ADDITION[Prev. Sanitation Permit# -------..----------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ----------------------------------------------------------------------•----------------------------------------.---- ----------------------- Disposal Field fSpecify Requirements) ------------------ ---------•--•-;-------------"---------------------------------------- - ----------------------- --------------- ----------------------------- ---- ------------------ ----------------- - ------------------------------------------------------------------------------------------------------------------------ (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, 'dad 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 as to become subject'! rkma 's Com nsation laws of California." Signed-------.----�- '` Owner . BY - -------- = Title --------- ----- ---------------------------------------------------- __.---- (I-f-other-than owner) - --.._--FOR DEPARTMENT USE ONLY / APPLICATION ACCEPTED BY ..... BUILDING PERMIT ISSUED ------------------------------ --------------------------------DATE _..---------------------------------------- ADDITIONAL COMMENTS - - - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- --------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- ------ ----------------------------------------------- Final Inspection by- --------------- - --------- -- - - ----------- - ----------------------------Date � ,-=��=-� --- - ---- --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'b8 Rev. 5M