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OR OFFICE USE: ' `APPLICATION FOR SANITATION PERMIT �� > ---------`y----------------- --------------------------- (Complete in Triplicate) Permit No. _______________________________________.__________--_ 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 with4ae ty rdinance No. 549 and existing Rules and Regulations: 17 C_. I JOB ADDRESS/LOC ION - __.- -_ _ - . -------- -------+ -_ 4- -- ---_ ---CENSUS TRACT -- + ------- ----- Owner's Name =1 ._/,, Pone -------------- Address ---- -------------- 3 a- -,,,V - -----------. City f" Contractor's Name -- - .--- _ _- - --------------License # � -I ---- Phone _- -G ----.- ------------------------------ - - Installation will serve: Residence Apartment House,❑_CpMmercial.:❑Trailer Court i❑ F Motel ❑ Other -------------------------------------------- Number of I'iving units:_-_1--r•Number,of bedrooms , _..Garbage•,Grinderl� rA- ---- Water Supply: Public System avid name f,.j_c:�,_-_�-------------------------------------------------------------Private ❑ Character of�soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑� Sandy Loam ❑ Clay Loam ❑ f h i Hardpan ❑ Adobe'[ Fill Material ZVO.__ If yes,type _______________________ --- (Piot 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_____ _ ',S�C�_ :__ -: Liquid Depth Capacity _.1,_1_10 v---- Type Compartments ,,: -_________--___ Distance to nearest: Well --- _____Foundation __ ______ ------------------- � - ----`--- Prop. Line�------------.... 1 LEACHING NE [ ` No. of Lines=------ ----------- Length of ch line------�_r ___�--.-:-_-Total Length,l:_ f1--r_.------ r' t i ___De th Filter Materi 'D' Box -- Type Filter Material - p al ____ -------------------•-----.-____-- s TDi'stance to nearest: W611 ---------.-------____-__ Foundation ---- _ --------------,Property Line ______._.__. i SEEPAGE PIT [ Depth __a.S___1------- Diameter ------- Number _________________ Rock Filled Yes y No 0 Water Table Depth ------- ---- ---------------- -------Rock Size ----------- _Foundation _._-.-______ Distance to nearest: Well --------------------------------------- -�___-- Prop. Line -. ..'...----------- � s REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------- ! SepticTank (Specify Requirements) ------------------- - ------------- --------------------------- -----------------------i------------------------------------------ Disposal Field (Specify Requirements) ----------------------------------------------------------------- _ ----------------------------------------------------------------------------------------------------------------------------------------- -41- (Draw existing and required addition on reverse side) I hereby certify--that'l 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: "1 certify that in-'the performance of the.work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------ --------------------~------------ -- ------ Owner BY -------------- ;------ 1�.1 Title ---- --- -- - - -- -------------------- (if of a 'owner) t� FOR DEPARTMENT USE ONLY ' 4 APPLICATION ACCEPTED BY - ------ ----------------------------------- ----- DATE ----�a -`p f ----------- BUILDING.-PERMIT ISSUED _-_-- DATE -------------------- --�-_-- -- ---____ ADDITIONAL COMMENTS ___ ._ r_ ---------------------------------- ---------------------------------------11------------- ---------------------------------------------------------------------------- ------------------------------------- a ----------------------------- -------- ------------------- -------- ----------------------------------------------------------------------------------------------------------------------------------- -------- -- ---- -- --- -- ---- - Final Inspection by: -----, --------------------------------------Date )-r---j --_-`----- i .SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M i