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FOR OFFICE USE: l J J 1"i C �t( `'�-.cr U �- l - U C_U PLICATION FOR SANITATION PERP r F-------------------------------------------- Permit No. `_/7... (Complete in Triplicate) -------------------------- ---------------- ------------- J Date Issued ' -----------------------_---------- --- Thls Permit Expires 1 Year From 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. 549 and existing Rules and Regulations: %/v 7�rk- S__-CENSUS TRACT -------------- ........... JOB ADDRESS/LOCATI N .__.._------_-__-- `� Owner's Name --------------Phone ---------------------.._...,..-.---- Address ----,�--------;X#-- ---------------•-------. City ,._ --••------------••-••-•---- Contractor's Name .---- ----- J License # � ��' Phone Installation will serve: Residence �artment House❑ Commercial:❑Trailer Court ❑ Motel ❑Other ---- �/�------------------- 5 Number of living units:__________ Number of bedrooms ____`lGarbage Grinder ------------ Lot Size _____________________ ___.__-...__.___- � Water Supply: Public System and name ----- --------------------------------------------------------- -------•--------------•-------------------------Private Rr i Character of soil to a depth of 3 feet: Sand ❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan Adobe:❑ Fill Material ________-_-_ If yes, type -;________________..___.___ (PI'ot plan, showing size of lot, location of system in relation la wells; buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size_ ;- X----' ----------------Liquid .Depth �i----------------------- Capacity . :z- - ----- Type - Material__ No. Compartments _ _...- _...__. Distance to nearest: Well ------..'-+©----------------------Foundation -----1_Cr._-------- Line .__-s....:-._-_--- LEACHING LINE [� No. of Lines _ ____...,___.____ Length of each line-'___.-6o------------- -- Total Length -_-------- ---- __ ________ � D' Box - . Type Filter Material -----�.,F_�_....Depth Filter Material ____f___________________�___..,...-.__-- �' , Distance to nearest: Well _______�_._ .._._____ Foundation _____._-L_�r.?___._-_ Property Line, �____________________ SEEPAGE PIT [ Depth --as.- ------ Diameter --- ": Number ------- _._/__ _ _ ___. Rock Filled Yes �No C] r ot, �1 Water Table Depth ---------- --------------5i--- ....... ....Rock Size ---=5 -�-------- Distance to nearest: Well ----•......./0D....................Foundation ------ -0.-`__.___. Prop. Line _! ................ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------•--.--.-----------------) SepticTank (Specify Requirements) ---- -----------•-•---------------------------------•--------------------------...----------;--------------------- -------------- ------------- Disposal -Field" (Specify Requirements) _-•--------------------_ -------------------------------------------------...----------------------- ---------- -•--------------- ------------------------------------------------------ -----•---- ------------------------•----------------------- ---------------------•--------------------- ------------------------ ------------------------------------------------------------------ ----------------------------------------- ----•------------------------------------------------------------------------ -------------- 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 k 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------- - - ----- Owner By -------- ......--- ��' - —------------------------------------. Title . '''� '�" (If other than owner) FOR DEPARTMENT USE ONLY p j APPLICATION ACCEPTED BY -------------------------- DATE -�--------------- BUILDINGPERMIT ISSUED -----------------------•------------------------------- ---....-..-------------------------.-------------DATE -------------•----------------- ----------- ADDITIONALCOMMENTS -------------------------------------------------------- ----••-------------------•---------•-------------•------------------•-•---=--------------------------- ! -------------•--------------_------•---------------------.._.. -------------•-•---------------------------.----------- -------------------------- ----------------------------------•--- - .__-______-_____._._______---- ________ __ nal Inspection by ----- ---• -- ------- DateQ----f;x rT SAN JOA QUIN LOCAL HEALTH DISTRICT 9 1-'68 Rev. 5M