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FOR OFFICE USE: FIV9 11 APPLICATION FOR SANITATION PERMIT --- •------------------------ -•- Permit No. ��_=��_J._� (Complete in Triplicate) This Permit Expires 1 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 exi ingyRules and Regulations. JOB ADDRESS/LOCATION ._: 1_-7(C' 0 � ' G + XJ - ENSUS TRACT ------ ---- -------------- Owner's Name .... -------- �• !d --------------------------=-------- Phone ----------- ------------------------ - - -- Address -- �`7-- -------------------------------------------------- ---------_. City ___,040d17 --,04 ' -1----------------------------- ---•---- Contractor's Name ----_-�rre---' �� ---------------------------------License #� �� Phone � . Installation will serve: Residence A Apartment House❑ Commercial❑Trailer Court ',❑ ,,// Motel Other -------------------------------------------- Number ---------------- ---------------------- -- o g _!.__.._ ❑ g ��_i .l ------------- Water y/-----..... Number of living units:.___ Number of bedrooms _________.__Garbo eGrinder}�,�'�_ Lot Size Water Supply: Public System and name -------------------------------- ------------------------------------------------------------------------------PrivateX Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,gt' 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�publ is sewer is available within 200 feet,) le PACKAGE TREATMENT { ] SEPTIC TANK Size___ xfxl;� ----------------- Liquid Depth 4�--------.--- ---- Capacity,2-Jf40------ Type/ow ' __-- Material_ / �___ Na. Compartments _ _______________ V Distance to nearest: Well __. Q _�_---------------Foundation /r2----_-_.____- Prop. Line f___._..__ p, LEACHING LINE ] No. of Lines .._ .__----------------- f Length of each line:_/A_P_ ---------- Total Length 'DBox 'V- Type Filter Material q Depth Filter Material� ___.________________�----------- Distance to nearest: Well .y�/..._.._ Foundation _, ll?�- Property Line ............... SEEPAGE PIT fZ Depth _ �_ � ,-7,�.- �_ __.__��. ,� �. _ ___ Diameter Number --- .___ _ Rock Filled Yes No i❑ Table Depth -----&__-----------------------------_ -__.Rock Size - ----------------------- Water f Distance to nearest: Well - �� ----------------------Foundation 1 ._ _______ Prop. Line 3 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I Septic Tank (Specify Requirements) ___.__________________ --------------- ------------------------------------------------------------------- - ---------------------------- Disposal Field (Specify 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, 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 as to become subject to Workman's Co pensation laws of California." .ter Signed -------------- --- --------------- - --------- --- Owner --------------------------------------- - v i By -------- -- --------------------------------------------- Title --.. . _ - -- --------------------------------------- ther than own r) ge FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---- -------- --- ---------------------------------------------------- ------- DATE /�----------------------------------- BUILDING PERMIT ISSUED --------------------- --------- ------------------------------•-------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------ ------- ; —� I----- ------- --- Final Inspection by: ------------------------------Date/ ---------- - - ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M