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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r� r4 ----- - --- ------ -------- ---------------- {Complete in Triplicate} Permit No. ...w --------------------------------------------------------- tt� 11 ---- 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 made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS/LO TION7-XMpartment �7 n ------------ CENSUS TRACT --- ; Owner's Name �J�71--d- --Phone -- --------------------------------- ' --: Address (��1 -— City - { Contractor's Name ....... _It _License #,f �', '_ Phone ______________________________ .. ._ ... Installation will serve: Residse❑ Commercial:❑Trailer Court i❑ } Motel ❑Other ------- Number of living units:____f_.__ Number of i3edrooms __Garbage Grinder __________ Lot Size __ --------- Water Supply: Public System and name ------------------------------- ----------------------------------------------------------------------- Private fJ Character of soil to a depth of 3 feet: Sand'❑ silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ' I Hardpan Adobe-E] Fill Material ------------ If yes, type ------------ --------- --- i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �} I NEW INSTALLATION: (No septic tank or see age pit permittedif �b)ic sewer is available within 200 feet,) y PACKAGE TREATMENT [ ] SEPTIC TANK:[ Size4//_X r _ ,-r-f1_r�___ ------------ Liquid Depth --- t Capacity_ 0__ Type ( +- ___ Materi .. t�-tA.e No. Compartments cam_____ _________ Q tance to neare . Well ---------�-FFJ_ -----------------Foundation __/Z_7_--___________ Prop. Line _____S ______...... LEACHING LINE { No. of Lines ________________ Length of each line____�t,----_------------- Total Length '6__4PQ_.______________.. D' BoxType Filter Material Depth Filter Material ----1�g--- ------------------------------ � _ Distance V_n__e__a__rest: Well ___--------- Foundation -----,_(f?_.r___________ Property Line ---- . �SEEPAGE PIT [ Depth --- -S___----- Diameter __ �' Number _____________ :_______ Rock Filled Yes No Water Table..Depth---------------Yg---------------------------Rock Size F Distance to nearest: Well ______________J__Q___O�___......-__....Foundation ---1_0__C___.---- Prop. Line f �� I REPAIR/ADDITION(Prev. Sanitation Permit.# -------.----------------------------------- Date --------------------------..------) I Septic Tank (Specify Requirements) ---------4--------- -- -- ----------------------- 3 --------------------------- Disposal --------------- ----•-Disposal Field (Specify Requirements) ---------- -------------------------------------------------------------------------- a --------------------------------------------------------------------------`---------- ------------------------ I ---------- ----------------- - (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 Lawsr 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 ---------------------- ---a__�--- -- Owner 1BY ----------- --------------- -- ---- Title v--------------------------- ---------- -- - (if other than owner FOR DEPARTMENT USE ONLY + APPLICATION ACCEPTEDB = --- --------------- ---------------------------------------------------------------- DATE -0-7--�--------- BUILDING PERMIT ISSUED --------------- ------------------------------------------------------------------------ --------------DATE ----------------------------------- ---•--- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------- .-------' --------------------------------------------------------------------------------------------------------------- ---- ------------------------------- - -------------- ---- • ---- - - --------------- - - - - ------------------- &- ---------------- ----- - Final Inspection by. = pate --- �J - - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'68 Rev. 5M.