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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --=----- ---------- - Permit No. - ------------------------ ------- II "-"" (Complete in Triplicate) -----------------------------------1I- ---- ------- - Date Issued ------=---------- - ------------------------------------------------------- This Permit Expires 1 Year From Date Issued II. 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/LOCATIONI� --- -- -- - - ------- ---' ---------------------------CENSUS TRACT -------------------------- Owner's Name '�' one --- ' CV -G -. city =Address --------- ZF Contractor's Name —E... --� � �#-#%. ---- License # "��-��'- � Phone -------------------------- Installation will serve: Residence ❑ Apartment House❑ Commercial :[]Trailer Court ;❑ I Motel ❑ Other --- Number -Number of living units:.".;-I__--- Number of bedrooms -__"""--_""_Garbage Grinder ------------ Lot Size __t-_- ---- 4- t --------"---- 1. -------Private Water Supply: Public system and name ----------------------------------------------------------------------------------- - Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ®Adobe.0 Fill Material ------------ If yes, type --__--__--_---""-"_____--- (Plot plan, showing size 1�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 ifpublicsewer is available within 240 feet,] PACKAGE TREATMENT [�f] SEPTIC TANK f A Size_ ---- --- ---- --- arLiquid Depth ------` ---------- -----• �1 app 3'" Capacity _�. ®DVWell Type Material - No. Compartments 1 'I . - 4 ------- Distance to nearest: _-_________ ------- = -Foundation -- ----------------- Prop. Line ___-- �- ev LEACHING LINE I yf No. of Lines ----" I-------------- Length of each line------1-q D------------- Total Length r+-_/_""._-_•-------...-.---- D' Box ------ Type Filter Material --- -- ------Depth Filter Material ------ - -- ----- ...------------ il k i Distance to nearest:-Well -_. :.'"_-------- Foundation _----/-�2"------------- Property Line '_----__" it SEEPAGE PIT [ Depth ____ -- ---- Diameter "-- _ "_ Number _ __-.__"_-- Rock Filled Yes No t RocSze " "_ `7�____ _ ------ -- Water Table Depth ----------��--------------------------- ----- ki - � o ca------ -------Foundation --- tl c-------- Prop. -_ ---------------- l distance to nearest: Well ____"-_- ""--f----------------- __""_- - - PLine / REPAIR/ADDITION(Prev. 'Sanitation Permit# ----------------------------------------------=------ Date ----------------------------------j IM , Septic Tank [Specify Requirements) ---- ---------------- ------------ ---- ------------------------------- ------------ ----------------------- Disposal Field (Specify Requirements) ___________-- --- --------""----- -- ""--- "-----""-" ------ ---------------------------------------------------------------------------------- -------------------------------------- -------------------------------------------- --- ------------------'=-- ------------------------------------------------------- - ----------------- --------- (Draw existing and required addition on reverse side) with San Joaquin I hereby certify that I have prepared this application and that the work will be done in accordance w 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 A -- = asto become subject to Workman's Cam ensatiAn lawmis of California." 1 - Owner Sig ned ----------------------------- By - ------------ -- -_ �. ►' __ -�--eL__- Title ------- -----. -`5v- ------ ---------------------------- " (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEI? BY ------------------------------------------- DATEl'---------------- - ---- - - - --- --------------- BUILDING PERMIT ISSUED -------------------------------- -- - --- DATE ADDITIONALCOMMENTS ------------- --------------------------------------------------- ---------------------------------------------------- il, ------------------------------ ----- -------------------------------------------------------------------------------------------------------------------- - -------------------------------------------------------------------- - ------------------------------------------ -- -- f Final Inspection by: Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. Y