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APPLICATION FOR SANITATION PERMIT P e r m 1 t s, a (Complete in Triplicate) This Permit Expires 1 Year From date Issued Date Issued ________ _______________ ______ _ ---_.____ _.__ ' MF 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - --1--+--- -_ ____ ' - - _00- ----- -- -----CENSUS -RAC// ---------------------- Owne's Name --------- ----- -- - ------ -------- ------------•-------------------Phone -t0-_o'�� ,�---- li]Address ------- ----------------- ------------ ------ - J� City ------ // pQ/// i Contractor's Name -----' ------ - -- -------- ---------.License # --------- ------ Phone�fo'"_ h.Q7_ —Installation will serve: Residence ❑ Apartment House❑ Commercial railer Court ❑ 1� Motel ❑Other ----------------------------------------- i Number of living units:._._Q_---- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ----------- ------- Water Supply: Public System and name ----------------` ----------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: 6nd,�❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam.F] Hardpan❑ j Adobe Fill Material ---------- If yes, type ---------------------_______ (Pl*Yplan,! showing size of lot, location of system in relation to wells, buildings, .etc.. must be placed on reverse side.) NEW INSTALLAT,IONI21444{No:septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGEfTREATMENT [ ] SEPTICTANK'[ ] S' e______________ -_x_-!_ `�* L�quid Depth --_---� ------._.. '' !! / �G. "`""" P Y /.' k - YP f_,- v No. Compartments � I Ca acct 3rOU- - Type _ - - --.Material-- -- --- -- - - -•---�..----=---- tom. — ' ,... ._ t " Distance to nearest: Well ----- --� ___-- ------ .Foundation ___l0- Prop. Line -----0--__------- ll LEACHING LINE [ ] No. of Lines ----- #/---------- --- Length of eachline-------F Q_�--------- Total Length/------F-____.............. C - D' Box ----V"_ Type Filter Material _ ____ __ _______Depth Filter Material -----/1?-------- .__________________-__-- ' Distance to nearest: Well __.:__ -Ud_ _____ Foundation—!---1-0_f_____.--_ Property Line _________4______________ l t SEEPAGE PIT [ ] Depth ---2. _�_____ Diameter1 _X3________ Number _.__. ---------------- Rock Filled Yes No i❑ i Water Table Depth ___________ Rock Sizel____ �'_______ Distance to nearest: Well ____________Foundation _________________ Prop. Line ___________ .......... ' REPAIR/ADDITION(Prev. Sanitation Permit# _.__-_- " --rjDate Septic Tank (Specify Requirements) --------------------------' -----I-------------- ---------- ---------------- ------------------------- r Disposal Field {Specify Requirements} _____________I--------------------- ___ _ _-_'` __ I_ J -------------------------------------------- ----- --------- -- ---------------------------- ------ --------------------------------------- ---- ------------------------ t � 4\ � j ��----------- ------------------------------------------------------------=-------------------- ----------------------------------------------- ------------------------ ------ [Draw existing and required addition on reverse side) j 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. dame 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 i as to become subject to Workman's Compensation laws of California." Signed --------------------------- ---- - ------------------------------ Owner l BY -r--- ne _ ---------------------=------ Title " �r -:-i---_- (If otheh n owner) "`� FOR;DE ME i USONLY _. APPLICATION \ACCEPTED BY -' _ -- - ' ------ ----------- --- --------------------------------------------------------------------- DATl ------ BUILDING PERMIT ISSUED --------------------------------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------------ -----------------J-------------------------------------------------------------------------------------=--------------------------- ---------------- -- ----------------------------------------------r------------------------------------------------------------------------------------------------------------------- ----------------------------------- --- ' ------- ----------------------- - --------------------------------------------------------------------------------------------------------------------- 4 ----- ----- ------------------ --------------------- FinalInspection by: ��M+a - - ------- -- ----------------------------------------------------- ------------Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.