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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete In Triplicate) Permit No. ..r.�0. . ......................................................... This Permit Expires 1 Year From bate Issue 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: Q - i JOB ADDRESS LOCATION ................CENSUS TRACT Owner's Name _..-•--------.... �.. .� .... r.. :..:.........................................Phone . Address City ........ :..:....:. ...... .... . ......._.... ...._.._........................... Contractor's`Name _A6—t,—_ „� -q°--- -, - ..License # r 'S� 6 6 0 5� .. Phone ..`1�__.....- .... Installation will serve: Residence Apartment House I-] Commercial ❑Trailer Court C "..Motel [❑Other................:........................... . , ,� Number of living units:--•-r__--:-- Number of bedrooms -•--••__----Garbage Grinder ......... Lot Si .��. �-Z:.................. Water Supply: Public System and name-:__-.. � _.... .. _. ...........Private ❑ Character of sail to a depth of 3 fe 6t: Sand 0 .Silt❑ Clay 0 Peat Sandy Loam 0 Clay Loam Hardpan �] Adobe9 Fill Material ............ if yes,type .•............. ............ (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 E tank or seepage pit permitted If public sewer.is available within 240 feet,) � PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size....__........................................ Liquid Depth Capacity ------------------ Yype .. -•--•-----_... Material.--- ---•---•--•...:.. No. Compartments ..................... Distance.to nearest: Well -�.....................•.__........Foundation ..................._.. Prop. Line ...................... LEACHING LINE [ j No. of Lines _. -----------.� Length of each line...................•.._..... Total Length ............................ f 'D' Bax ........._._ Type Filter Materia) ....................Depth Filter Material .......:.......I............................ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ ( Depth ----- --- Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ Water Table Depth -----•--••---- .................................Rock Size ................................ Distance to nearest: Well ....................................... Foundation .... ................ Prop. Line ...................... REPAIR/ADDITION{Prov. Sanitation Permit# ...................................I........ Date -.._-----._-------..__••-.-_------) Septic Tank (Specify Requirements). .......... ................. Di�Posai! Fjeld S ecify Requir menta) . _...._- Y_ -- '-•• :,x ft.. ..,�?.-:---.... lI'--•-- •--•----- ! r _ G - •a-. �--� - ................. I(Draw existingand re d addition on reverse side) '�' I hereby certify that I have prepared this appiication-ant{ that the work will be done In accordance with San Joaquin County Ordinances, State Laws, aWd Rules and Regulations of the San Joaquin Local Health:,District. Home owner or liter- 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 becoNe ub t to orkman's Compen ation laws f alifornia." Signed ----- A - fi � By -------------• -----• :?s_ .. Title 1If other than owner) t t FOR DEPARTME ONLY APPLICATION ACCEPTED BY ------.-I---------- - �`' �` DATE ��✓�� ------------- --- ------ BUILDING PERMIT ISSUED ...._. ------ ------------------------------- -----•--- ------- - • ------------- ---DATE ........... .......... ---------------- ADDITIONAL COMMENTS ......... !---------------------------•-- ..... - :... i r - _ -• --•-•--------- ----------•---• -•--- •- - ------- _ -----. -•-------------•--•-------•------------ -- ------------•----- ---•------•-•---------._...-----------__I.__..---------------•_...--- ------- FinalInspection by: --------------------------'-----•-••--•--•----•-----------•-----••--•---•---. ---•---------- Date ......... 61`7 `.'IC-..---- - ----------- IM 13 24 1-$13 Rev. 5M � SAN JOAQUIN LOCAL HEALTH DI CT 8/74 3M CO C