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FOR OFFICE USE: ^ � '7i-.syr AE.,-KATION FOR SANITATION PERMIT - - ------------------------------ Permit No. ��! 5 (Complete in Triplicate) - ------=-- "--------------------------- ---------- This Permit Expires 1 Year From Date Issued Date Issued Illf Application is hereby made f the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is mad``a in compliance with County Ordinance f1Ncayo. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N �__ 1 _ � --� rr __L_Y---CENSUS TRACT OSt l�0:-1� Owner's' Nam ---------------------------------------------- Phone Address O_L ` C� City - -----------------------------------� ---.------ Contractor's Name _.___ r - ___ -_ `__ ----------License # Phone _____________________ Installation will serve: Residence ❑ Apartment Nouse,❑ Commercial :❑Trailer Court IC7 Motel ❑ Other -------- Number ------Number of living units:-----I------ Number of bedrooms _>�:7�_Garbage Grinder ____________ Lot Size ______-___________________________________ Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------_Private Character of soil to a depth of 3 feet: Sand'❑ ilt❑ Gay E] Peat E] Sandy Loam -E] Clay Loam ❑ Hardpan Adobe❑ Fill Material ------------ If yes,type ______________.____-__ �t (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 Capacity -------------------- Type' _---------- ------ Material---------------------- No. Compartments -----------------_-- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------- ...... LEACHING LINE [ ] No, of Lines ________________________ _Length of,`each line-------- ------------------- Total Length ,___-_-__----__--.-___-.-__ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.___.__---------__------ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -------------------.---- SEEPAGE PIT [ ] Depth Diameter ----------- ---- Number ---------------------------- Rock Filled Yes ❑ No 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) __ _ +-� -_ __---_ T - ------------------------------ - :�- -------� -----------�- -------------- ---- ------ ------ QQ .� X Ls .2 - - ------------- - ------------ - ---------- - ------ ---- ----- (Draw existing and required addition on reverse side) I hereby certify hat 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 bec a subject to rkman's Com nsation la s f California." Signed - ------ Owne -�1 By -------- Ti#le --------- ------- ----------------------- (If other th o ner) _ FO* DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --_ -- _ ------------------------------- DATE �`f-41`�f---------------- - - -- - - -- - - - --------------------------- BUILDING PERMIT ISSUED ------------------•'---------------- ---- ---------------- -------------------------------- --------------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------- ------------------------------------------------------------------------------------------------------------ --------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----------------------------- c ------------------------- ---------------------------------- Final Inspection by: --------------------------Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M