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C FOR OFFICE SE: 6. /O.- /3 7a APPLICATION FOR SANITATION PERMIT - - -- - ---- , / Permit NO.,ai_ (Complete in Triplicate) --- --... �--�� ----' ----- - - - Date Issued _ --------------------__----- _ --------_---- ------ This 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 Ordinpnce No. 549 and existing Rules and Regulations: 3 . JOB ADDRESS/LO TION .. .-_ _-,___ .__ _ _ G`."_______CENSUS TRACT __ --- Owner's Name �L '/ - --- ------------ ----- hone- Address ----- -T - j - - - ... . ..... City - - ------------ -- - ------ ... Contractor's Name ______ - t[. _ - ___ _ _____________License #f-' ��--- Phone ------- Installation will serve: ResidencegApartment House❑ Commercial ❑Trailer Court i❑ Motel F1 Other -- --- - ------------- Number -- _Number of living units:.---t ----- Number of bedrooms _'__Garbage Grinder --------- Lot Size ..._- �� ------------------ Water Supply: Public System and name ----------- -------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe K Fill Material ------------ If yes,type ---------- r (Plot 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-_____-......----- __.._.__.-__-..-.-_--- Liquid Depth -- --- . Capacity - --- -------.Type ------------------ Material---------------------- No. Compartments ----------- Distance to nearest: Well ----------__--------------_____...Foundation -------- ------------- Prop. Line --__________....__- V LEACHING LINE [ ] No. of Lines ------------------------ Length of each line__------------------------ Total Length -----_.__-_-..___....__ 'D' Box -------- _. Type Filter Material --------------------Depth Filter Material -----------------------------____________. ` Distance to nearest: Well,------------------------ Foundation -- -------------------- Property Line ---___________________ SEEPAGE PIT [ ] Depth --- -- Diameter ----_-----.... Number _- ------ ----- ------- _. Rock Filled Yes ❑ No I❑ ►. 'Wat4r Table Depth --------------------------- ---------------- Rock Size --------------------- -- to nearest: Well -_--- ---------------------------------Foundation --------------_.--- Prop. Line ---------.._-__--_--. REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------. ---__ Date ---------------------------------- Septic _.________-_._______________Septic Tank (Specify Requirements) ------------------- ---------------- -------- — -.. .^ --- '------------------ _ - ---may^--�--� Disposal Field (Specify Requirements) -- ------ -�--- - - { - --- `'- -`----=-1------------- -- - -------- --- - �� 2�------- - ---- ---- - ---- ------------------ - - -- ------- ----------------------------- ------ --- ----- --------------------_-- -- (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 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --------------------------------- ---------- ----- ----r'---- - >Owner By --------- - t - Title ---------------• - - - ------------ - -- _.... - - (If o or t n wner) F R DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY --- -------------- is1 - ZL------ --------------------------------------. DATE �' �- ?d --------------- BUILDING PERMIT ISSUED - - --- -------------------------------------- - - --- -- DATE - --- -- -- - ADDITIONAL COMMENTS - ----- ---- - -- -------------------------------------- ----------------------------- -------------------------------------------- ----- w. -------- ------------------------------------------------------------------------ ------------ - - -------------------- - - - - - —� —�} -- - ------------------------------ ------ ------------------------------ - -- ----- -- - - -- - ---- -- --- - Final Inspection by: --- --- � -- - - - ------------------------------------------------ -- - -----------------.Date -------------------------- - ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M