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FOR OFFICE USE:. APPLICATION FOR SANITATION PERMIT Permit Na. --------- ---------------- ------------------------------ (Complete in Triplicate) ------- ------ --------------- ------------------- ?-- - ---- - Date issued _..� --------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 5A9 and existing Rules and Regulations: l 4/ 7.77- --//I,-----0 ----------- JOB ADDRESS/LOCAT N _ - Phone------------------------------------- Owner's Name ---- ------ eA - ----------------------------------- ------- --- ---�. -- -- --- --- Address ---------- - -•----- CitY ----------------- --------------------- ---------- r a ------ Contractor's Name____-- -- --- ---- •------License # --��_.a�-8_�__ Phone ----------------------•- Installation will serve: Residencertmenfi House Commercial ❑Trailer Court ',❑ { MotelOther -----------I-------------------------------- ooms --- ---Garbage Grinder Lot Size ___-______------------------ Number of living units_____________ Number of.bedr ------------Private Wafter Supply: Public System and name ----------------------•--------------------------- ------------ Character of soil to 1a depth of 3 feet: Sand❑/lilt❑ Clay ❑ Peat E] Sandy Loam ❑ Clay Loam.❑ T I Hardpan Adobe'❑ Fill Material ------- --- If yes,type ---------------------------- t (plot plan, showing size of loft, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep 'e pit permitted if public sewer is available within 200 feet,) o SEPTIC TANK' �I �-_T------------- Liquid Depth _9---------- --------- PACKAGE TREATMENT [ ] [ Sizey$-___x_g----- • D d Material ___------- No. Compartments -----_..--� ---•- - Capacity _� ----- TYpe ----- - -- 1 �- - -_r _ ._ -- Y Distance to near t: Well ---- -- ------- -- ---------- -•Foundation -__----�6--------- Trap. Line ---- -----;-•- Length of each Iine_-------1--o-©------------ Total Length��----------------------------- V LEACHING LINE [� No. of lines c •.- _. 1 D' Box -- __---- Type Filter Material __ �Z-'--4 -Depth Filter!Material --_-- ----- ---- V Distance to nearest: Well -4-.__ ®-----------'Foundation �d-= --::--------Property Line -'S SEEPAGE P17 , De th - __-- Diame'ter___�3 _--`- Number ----.------Q------------- Rock Filled Yes 2 o I❑ [ p -- - ,,.a 1 P �• 10 y Water Tablie Depth --------------- --------- --------Rock Size J� '---------- + r r f 1 Distance to nearest: Well -------------)b_n----------------- Foundation ------ -p--------- Prop. Line ---------------------- Distance ------------------ - 4 f� s -- ---------- ---- Date ----------------------------------} REPAIR/ADDITION(Prev. Sanitation Permit# _-----R ---=----------- , l ------- i --------------------------------------• Septic Tank (Specify Requirements) --------------------------------------- Dis I Field (Specify Requirements) --------------------------------------------------------------------------------- - '. -------------------------------------------------------------- ---------------------------- ---------------------------- ---------------- 1 (Draw existing and required addition on reverse si e 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 man's Compensation laws of California." I Owner iSigned ---- -------------------- ------ --- ---- --------- --------- ---- - Title —�-hAA —a ----------------------------- y; (If other t n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - -------------------------------- DATE _ _-__ - - - --- - ------------- :�N'�� ---------------------------------------DATE ------------------------------------------- BUILDING PERMIT 155UED ---------------------------------- ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ --- - ---=------- ---- ---------- ------------------------------------------------ -------------------------------------------------------------------------------------------------------------- ------------------------------------ -------------------------------------------- --- ------------------------ - ---------- ----Date :------- -------- -- ----------------- k Final Inspection by: - -•� ------------------------------------------------------------------------ SAN -------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M