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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- ----------------------------------------------------- Permit No. _ _. .Cf (Complete in Triplicate} ----------I------------------------ ------ -------------- This Permit Expires 1 Year From Date Issued Date Issueda �y 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'. 549andexisting Rules and Regulations: 11 JOB ADDRESS/LOCATION .-1- -g_Q____, �_ �/--- f�-��.it_ .--- 57_.;---I4 /_CENSUS TRACT -------------------------- Owner's Name -------- ------------------------------------------------------------- ------------------------- Phone --------------------------- -------- Address - ----- f��s'ai �' •_Z4� A*__ �l�pf� l City hF Contractor's Name ---��f_A�--= e ----------------------------------------License #j�9r _ Phone 0jf_ J__rZjg�A� Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Courts 0 Motel ❑Other -------------------------------------------- Number of living units:_-_ ____ Number of bedrooms ______Garbage GrinderG�?. 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 Loam ❑ Hardpan ❑ Adobe M 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.) r" NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer i`available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size__ __ ,F�_�--------___________ Liquid Depth Xi_.,-------------- Capacityla_19�____ Type/f . _ Material.�"Ql_ _.__ No. Compartments ____?r_____________ Distance to nearest: Well p_----------------------Foundation ,�C�_f____________ Prop. Line�4!_l............ LEACHING LINE No. of Lines V [ ] ---------------- length of each line-- 00-------- Total Length - ----:---.------ 'D' Box�(9_0-o9_0Type Filter Material 1126ejP4016epth Filter Material ----------------------- Distance to nearest: Well _ _�_�___- Foundation v' 0-_ ___________ Property Line ..ifs.__.__----_.__ SEEPAGE PIT [ ] Depth j_ _ ��-- Number ----Z-__________________ Rock Filled Yes$ No i❑ __�.�_ _ __ Diameter ___ Water Table Depth ------- _____________________________Rock Sizes!__ __r�1_40 Distance to nearest: Well ______ ...............Foundation Prop. Line .../--------- REPAIR/ADDITION ---REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------------:-- Date --------.--------------------------) SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------•-------------------------------------- DisposalField (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: "1 certify that in the performance of the work for which this permit is issued, I shelf not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------------- ---- --------------------------------- Owner BY -------- --------------------- -- ----�y( --------• Title ------------ - --- --- ------------------------------- (If other n owner- _ FOR .DEPA1t7MENT USE ONLY APPLICATION ACCEPTED BY DATE -cam- �'"'! ------------- BUILDINGPERMIT ISSUED --------------------------------------------------------------=-------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS - ------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ------ - ----- --- -- --------------------------------- ------------ - ----- ----------------------------------------------------- ---- Final Inspection by: -.- ---------------------------------------------------------------- Date . ~-�,_A SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M