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t._ FOR OFFICE USE: ; --------------------------=------ ---------------------- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued 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 ' gp�pliangg�yrq' i vo my Or irtonce No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ------- - h---------��-- u- -_U---------------- c' ------------- CENSUS TRACT ----------- Owner's Name ---------------------Phone y Address -------- --------- - �J '------ . 41r410--------- City ----- . - /-�-.-- ._ ------------ ie Name �" d � --- f-1-0----- A_&_ - License # Phon ----- ------------------- Installation will serve: Residence ❑ Apartment House❑ Commercial wrailer Court ;❑ Motel ❑Other Number of living units:-l_']0Y)_e_Number of bedrooms __ lo►1_C'_Garbage Grinder Lot Size __ O_-� - 142 6 --------- - Water Supply: Public System and name -----------------__---__-___+e__ _,f___ Private ❑ _j ---------------------------------------------------------.---- - Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe-0 Fill Material ------ if yes, - p , (Plot plan, showing size of lot, lok cation 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,) W PACKAGE TREATMENT SEPTIC TANK'Y Size______f_ - ---- Liquid Depth ----------�_-/----- � Capacity J'�zcv- . _ Type _ S_ J'- ------- Material ez_- No. Compartments - Distance to nearest. Well __ -- -- ------- --------Foundation _./.Q-----...... Prop. Line .------ ------ LEACHING LINE [A No. of Lines --_______�_----------- Length Length of each line-------- �_~._____- Total Length -.-----`�� J_ ------•- D' Box ._;0--_-- Type Filter Material ---�2--------------Depth Filter Material ---___-1 _ -•--------•- ---------- Distance to nearest: Well ___ Foundation -------- Property Line --____----------- SEEPAGE PIT [�] Depth ___ __-.--___ Diameter --- 6_-___ Number -------- ---------------- Rock Filled Yes 2No Water Table Depth -------------C __/----------------------.Rock Size -------!� _._ p � Distance to nearest: Well ------ ----------------------------------Foundation -----fc.�~__--- Pro , Line:.---------------__--- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------------- Septic -------.------------.-_ -Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- Disposai Field (Specify Requirements) ----------------------------------------------------------------------------- 1+------------------------------------------------------------------------- ------------------- -------------- -------------------------------- ---------------------- ----------------------- --------------------------------------------------------------------------------------------------------------------- (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: "1 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 ------------------ a ----------------------------- Owner f7 x� ---- ------------------------ ---- ------- By - ------�----------- --- ------------------- -- --- ------ Title _1�� (if other than owner) � - � r f TMENT USE ONLY APPLICATION ACCEPTED BY -------- R________ _ _ ______ _ ----- -- - ------- - --------------- -------------- - DATE --- -- --- ------------------------------------ ILDING PERMIT ISSUED _ DATE ..---.-_-- ADDITIONAL COM NTS ------ --- - - ----------- ------------ --------- - G� f y-------- - ----------- -- -----------I--------------- --- ------------------ - - - ------------------------- -------------------------------- - ---- p — Final Inspection by: ------------- -------------------------------------------Date -- ------------ --------------------- AN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M