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r FOR.OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- ----------- -----------------------------R Permit No: (Complete in Triplicate) ---------------------------------------------------------- ------------------------------------ ---- --------------- This Permit Expires 1 Year From Date Issued Date Issued __..__ --� Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o. 5. d e,�cfisting Rules and Regulations: JOB ADDRESS/LOCATION ----7 �__o�---,Olvn--- - - - -------------41p-yly A-__jCENSUS TRACT ---5-- - ---------- Owner's Name --- ' `� +t �� ' `�1--------------------------------------- -o-----:--------- ---------Phone Address ./7_7-a_ "---------------------• City s ��w Contractor's Name ---- -- 13 / ---------------------------------License # � /f _ Phone , '' ��C _ Installation will serve: Residence &_Xopo�artment House ❑ Commercial ❑Trailer Court ',❑ . Motel ❑ Other -------------------------------------------- Number of living units:_.____.__ Number of bedrooms _____Garbage Grinder Lot,Size '�%�' _______________ Water Supply: Public System and name ------------------ ------------------------------------------------------------------------------------------.Private Characterof soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .0 Clay Loam e— Hardpan � Adobe-❑ Fill Mciterial _ 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 flank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT f ] SEPTIC TANK'[ V§ize -_ _ ------X-_ - -------------------- Li uid De thf - .Typ4_' No. Compartments ------------ _.._._.__ -a----------------------Founation -f -- �f ------Distance to nearest: Well Prop. Line LEACHING LINE No. of Lines - Length of each line- Total Len thf'l ________________ C g line-/p' -------- -- g Type , Depth Filter Material/00f D' 8ox ✓ T e Filter Material _ _-___----------------------- Distance to nearest: Well 490---------------- Foundation ------------- Property Line �!?'�_________-__. _ U-1 SEEPAGE PIT j/�' Depth /--- Diameter � ------ Number ---�--------_._-___ Rock Filled YesA No I❑ r Water Table Depth _____ __ ___� _ Rock Size _________________ Distance to nearest: Well --------------------Foundation -------- Prop. Line _ !-____.___---_ REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ___________________-___-__-_______) Septic Tank (Specify Requirements) -------------------.__________ __ I DisposalField (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•--------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_------------------------ --------- --------------------------------------------- -- --------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required,addifion,on,reverse side) I hereby certify that I have prepared this application and' that'thejwcA 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 Compensation laws of California." Signed -- -------- -------- ---- -------------- _ Owner BY - v ` Title .. z� - - ----------- ----------- (If other n owner) FOR DEPARTMENT USE ONLY all 41 APPLICATION ACCEPTED BY - _____________________________________________ 1 - � - --- ------------- DATE --------------------- - BUILDING PERMIT ISSUED ? ------------- --------------DATE ------------------------------------------- ADDITIONAL COMMENTS = ------------------------- --------------- ------------------------------------------------------------------- ------------ - ------ --------------- --------------- ----------------------------------------------- 7!-------------------- ---------- -------------------------------------- ---------------------------------------------- ------------ ---------------------:--------------------- 3-----�---------------- s ------ - - ------------ Final Inspection by: - '- -—----------------- -------------- ---------------------------- ----DateC4 � - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M