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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT __ I Permit No. (Complete in Triplicate) ---------- ------------------ ----------- // Date issued This Permit Expires l 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: JOB ADDRESS/LOCATION ._I�_-�� Q 27 -- -----------------CENSUS TRACT -------------------------- Owner's _Na meIt -------- ----- -- `--- ------ - ------------- , ----------- , ------Phone ----- ------�-'—-------- ---- City -------------------- ------------------------------•---•-- Address Contractor's Name License # _1 _y Phone ------------------------------ Installation ------------- --Installation will serve: Reside ce KApartment House❑ Commercial :❑Trailer Court Motel ❑ Other --------�--/----------------------------------- Number of living units:-------1__._ Number of bedrooms __`t____Garbage Grinder ------------ Lot Size ___________________----____._______-.___._ i t` Water Supply: Public System and name - ----------------------------------- --Private [r i, Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay ❑ Peat E-] Sandy Loam -E] Clay Loam [�-^ r Hardpan ❑ Adobe [] Fill Materia! ------------ 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 tank or seepage pit permitted if public sewer is r available within 200 feet,) I i PACKAGE TREATMENT [ I SEPTIC TANK:[� Size_ 5__t _��-----r------:=- �'�------------ Liquid epth _V_--------------------- IP -C T e ---.�_ Materia i_�� -- No. Compartments __ P-_____________ Capacity YP + r 9 f � ° Distance to nearest: Well _____.____ �r �........1'----Foundation ._-------___--_--- Prop. Line ___�_______________ 9 - t LEACHING LINE, [� No. of Lines ------�_-____---- Length of each line----1_QQ--r___ ------- Total Length ---------__ on } 'D' Box �._ Type Filter Material __k___ __R-_....Depth.Filter, Material ---- '--------- -----�------•-----•- 0 l - Distance to nearest:"Well' ��'- �4- -Foundation z - - -------------- Property Line ____-____________.:____ ,.s .. . .._. SEEPAGE PIT [ Depth ----- ___- Diameter 2--1----- Number _.___... -__.___-- ---- Rock Filed Yes o Water Table Depth ---------------- a ------------=--------Rock Size --------•- Distance to nearest: Well ----------L1~1a------- ------------Foundation ----I-r'----------- Prop. Line ----- -------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -------- ------------------------------------------------------------------------- -------------- -- -------- ------------------------- 1 l Disposal Field (Specify Requirements) -------------------- -------------------------------------- --------------------------------------- ------------------------- -------- - --- ------------- - ---------------------------------------------------- --------------------------------------- ----------- ----------- -- s (Draw existing and required addition on-reverse•side) :y I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin I County Ordinances, State Laws, and Rules and Regulations of the. Son Joaquin Local Health District. Dome 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 ----------- god,--i_ Owner "Title _.._BY ---------------- ---------------------------- _ - (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ----------- DATE ------------------- BUILDING PERMIT ISSUED ------------------- DATE . ------------------- - ADDITIONAL COMMENTS -------------------------------------------------------------------------- --------------------------------------- ----------------------------------------- - ---------------------------------------------- =------- ------------------------------------------------------------------------------------------------- ------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------- Final Inspection by: __! -. - ----- -----------Date _f - d I SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M.