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FOR OFFICE USE: : . APPLICATION FOR SANITATION PERMIT J - _��--__�---�-•�� ------- ---------------------------• --------------"----- II (Complete in Triplicate) Permit No. ° - ---- --- --- - -- A _- - 76 �� This Permit Expires 1 Year From Date Issued Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i described. This application is made in compliance with County rdinance o. and existing Rules and Regulations: 1 I JOB AQQRESS/L ATIO ` - ---- --- ---- ------ ---- -----CENSUS TRACT -------------- ------------ Owner's Name _ ' ------------- ------Pho e ------------------------------------ ----- - -- -- -- - ----- - Addresse � � �' City - - -- --------- -----=------------------------------------ Contractor's Name --------I------------------------------------------------------------------ ----------License # ----------------- ----- Phone ----------------------•------- Installation will serve: Residence ❑Apartment'House❑ Commercial :❑Trailer Court '❑ j Motel ❑Other ------!--7--------- -------------------- �____ Number of bedrooms L.14 Garba e Grinder _ Lot Size ------ ---- ---- Number of living units:____ __- - - - --- g II Water Supply: Public System and name -------------------------------------- ----------------------------------------------------- Private E]Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan F] Adobe F-1Fill Material ------------ If yes, type ------ i (Plot plan, showing sizellof lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEWNo septic tank or seepage pit permitted ifublic sewer is available within 200 feet) �� PACKAGE TREATMENT TALLATION: (,i, SEPTIC TANK'} Size--- _x _ ------------------------- Liquid Depth '7.--- ----------------- '10 Capacity ;' - Type ----- Material_&V7Sc.t ____ No. Compartments - '---------------- � Distance to nearest- Well ...Sa__ Fou da ion ___1G_-----______ Prgp. Lin 1�_.... ------- --------- - LEACHING LINE ] No. of Lines _ j----- ------------ Length of each line------ ______ Tata! Lenth _.___----___._.- y� _Depth Filter Material __ h-__________-10----------------- 'Q' Box ��-- Type Filter Material _�'~�'--_-- - � - .Distance to nearest: Well _s "D`-- ------- -� ---- Property Foundation Line --- -------------------- 3 __ Rock Filled. Yes No 0 SEEPAGE PIT Depth �S - Diameter �______________ Number ____.____.____-- -__ i Water Table Depth ---6--0------------------------- -----------Rock Size ,A-1---/----------- -------- ii Le 0 Distance to nearest: Well -�_ �-_--"�---- ----------------Foundation D-_G�.----------- Prop. Line _47- ------------0 { l �.> REPAIR/ADDITION IPrev.i�Sanitation Permit e# -------.------------- -------------- Date ---------------------------------- Septic Tank (Specify Requirements) -------- ---------------------------- -------------=--------- ' i Disposal Field (Specify Requirements) ---------------------------------------------------------------------------------------- -------------------------------------------------------------------=------------------------ � --------------------------------------- ---------------------------------------- ------------------u- ---- -_--------------- -.,-------------------- -- ----------------------------------------- --------------------- - _ _ (Draw existing and required addition on reverse side) ! I hereby certify that 1 hlave 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.,biome owner orlicen- 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 g - Workman's Compensation laws of California." Signed 1subject to- 1 -------------------------------- Owner By ----- ------------------ll------------------------------------- ------ Title --- ---- ----------- --------------------------------------------------- (If other t °an owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------------- QATE 7 -- -------- --- BUILDING PERMIT ISSUED ------------------ --------------- ---------------DATE --------------------------------- ------ ADDITIONAL COMMENTS -------------------- -----=--------- f _______________________ _ ____ ______________ ___ _______ .. _ __II _ _________________________________________ _ _ ______ �� --------.Date ----- ----- Final Inspection by: _ ; __-- ---- ✓__L� ;} - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1.-'68 Rev. 5M