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FICE USE: �` :.�. • � �' K APPLICATION FOR SANITATION PERMIT -„g---- --------- -------='-- Permit No. __ w (Complete in Triplicate) �7/ ------------ � 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 mckde in compli c wit County Ordinance NO. 549 and existing Rules and Regulations: JOB ADDRESS LOCA _--`` ' / = - - ------ ------CE ACT --------------.-------.__. Owner's Names .. -- = =� Phone - / -- Address { R e J - City ---- -----------------•------ �IeContractor's Name ---------- �r icense # � hone Instal i will serve: ReWoltlel ❑ Apartment House❑ Commercial"f7railer Court .•� ' jDl Cr �l.. a ❑Other-.------ '----------------------- --------- um er of livin units------------- Number of bed ro m :________Gage Grin er Lot Size g Water Supply= Public System”and name ---------------- --- -..----- = - Private t p - Hardpan�Ado❑be ❑ Fi11❑Material �-___-- lf yesotype�-----Clay Loam ❑------------ Character of soil:t.o a depth of 3 feet: Sand' ,It "Clay Peat Sandy (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 avoilable within 200 feet,)_ Liquid PACKAGE TREATMENT [ ] SEPTIC TANK�[ ] Size________________________'------------------------ Capacity -----=-------------- Type -------------------- Material-----------'---------- No. Compartments ...................... Distance to nearest: Well '_____________________*__-_{___-__Foundation -----------------------Prop. Line -------- ----------------------- ;Length of eachline al Length •--.-- -------------- 'D' Box .- --------- Type Filter Material - De -----th Filter Material p - - G Distance :wirest: Well -----___- - . --- Foundation .-_-- -------------- Property Line. _ ___-- ------------- SEEPAGE - ---- --- SEEPAGE PIT [ ] Depth ____________________ Diam _________ Number - ----- __ ___ Rojo, Filled Yes No 0 i Water Table Depth - ---- ---------------------Rock Size - _--- -- --..-------- Distance to nearest: Well ------ ---- -------------------------Foundation -------------------- Prop. Line-.------ -=_=--:•--- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_} 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 , - -------- -- ' -- = of California." as to become subject to Workman s ensation law 1 p Signed ------------- ------------ -------------- . -----------_._ Owne BY -------------- # _ Title (If other than owned FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -=------------------------------------------------------------------------------------------- DATE -- �-S" / BUILDING PERMIT ISSUED ------------------------------------ ------------------------------ --------DATE -------------•-------r ------------------------------ -- ------------------ ADDITIONAL COMMENTS ------------------ -------------------------------------- - --------- -------------------------------------------------- ----------------------------------= ----------------------------------- -- --- ------------------------------------------------------------------------------------------------------------------------- ---------------------------------- �, Final Inspection by. Daf f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M