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i FOR OFFICE USE: a I APPLICATION FOR SANITATION PERMIT -----------------e '- i' (Complete in Triplicate) Permit No. --------------- This permit Expires 1 Year From Date Issued ©ate Issued :_ -'�-�.9 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 my Ordinance Na. 9 and existing Rules and Regulations: JOB ADDRESS/LO ION ------------ ------------ .' CENSUS TRACT . - -- -- Owner's Name - ------- ------------------------------- -------- -- ------ Phone . ------------------------ -------------- - Address' i ` ---1 n - -- ------- Ci#Y r Contractor's Name ------- ---- ------ _______•---__--.License# !_&Sif Phone ------_------------------------ Installation will serve: Residence Apartment House^❑ Commercial :❑Trailer Court ;❑ it Motel ❑ Other ---------=--------- ------ --- Number of living units:.--!______- Number of bedrooms __,_3--- Grinder _Y747 __ Lot Size --- --------- ------ Supply-' Public System and name ---------------------- ----------••--------- --- ,--------------- -----------------------------------Private [ Character of soil to a depth,of 3 feet:— Sand-'❑ t❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan. Adobe-❑ Fill Material ------------ If yes, type ------------------ - (Plot plan, showing size of lot, location or,see� e -relation to wells, buildings, etc. must be placed on reverse side.) \ NEW INSTALLATION: (No septic tank or permitted publicseweris available within 200 fset,J PACKAGE TREATMENT [-]' "SEPT[ TANKSiz / cS M EV`�, � Liquid Depth ---------------------Capacity __--- Material ---r No. Compartments , - _...:.--- istance_to-neare ----- P----_-_-- Foundation _____ �__-______--_ Prap. Line S ______LEACHING,LINE [ No. of Lin s -----.-- g f g C7den th of each ne-_____ __f]G__ Total Length --(�------- - --------- ll r L/ 'D' Boxlea Type Filter Material -- _-.I__ _Depth Filter Material ----- _ --------------- ----------- I - - - Distanceest: Well ..- -�. ---- Foundation ----to-,o-------------- Property Line -- ��No .---_-SEEPAGE PIT Depth --------------------- Diameter -- _---- Number -.----- -.-.---_-_- Rock Filled Yes i❑ ' Water Table Depth -------------- d 0-rj Rock Size _- -fl ---fir R Distance to nearest: Well .--_----- - 1 ------------------Foundation __-[_C]-_--.---- Prop. Line --Is-------------_ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_----.---_----_----_---____---_) s r Septic Tank (Specify Requirements) ------------------ -------------------------------------------------------------------------------------------------------------=---- ------ Disposal Field {Specify Requirements] -------------------------•-•--•------------------------------------------------------------------------------------------------=----- --------------------------------------------------------------------------------------------------------=------------------------------------------------------------------------------------------------ -------- ---- -- --- - - - ------------ - (Draw existing and required addition on reverse side I hereby certify that 1 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 Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in a performance of the work for which this permit is issued, I shall not employ any person in such manner as to become object to Workman' Co ensatr laws of California." Signed -----------rh ---------- --- --- ----- ----- -- ---- ------------------------ -- Owner BY - , ------------ ---- ---- ----- ------- ------ - Title ---- -------- ..�Q�=/C ---------- ----------------- than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ' --------- ----------------------------------------------- DATE --�/,_ ---------------- BUILDING PERMIT ISSUED --------------------------------------------------------------- ----------------------------- --------------DATE -- ---- ----------------------------------- ADDITIONALCOMMENTS ----------------------------------------------------- ---- --------------------------------------------------------------------- ----------- --------------- ------------------------------------------------•----------- ---------------------------------------------------------------------------------------------------------------------------------- --------------------- --------------------------------- ------------------------------------------------------------------------------------------------------------- ---- ------ ' ------------------ -------------- -------------------------- --------- - ---- ---- -- ---- ------------ ---- -- Final Inspection by: _ -------------------Date � --__- _ _ - ___-- -- _-_-- SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M