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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ------------ - ------------ ------------------ (Complete in Triplicate) - This Permit Expires 1 Year From Date Issued Date Issued -__�-~��'�/ ----------------------------------------------------------------------------- ---. Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein desgibed. Th' ap licoti n is made�in compliance with County Ordinance No. 549 and existing Rules and Regulations: �°-��1 7,r�J O �vl ��5 a� lsd ._ CENSUS TRACT __ _ JOB ADDRESS/LOC ��T y —� [ 9JlN'"C!- , -"--i "------------------------- Phone 7`��QI Owner's Name ____ // ------------- Cit ----- Address --------------------/ ' 1 y :: Phone SG��------- -7 Contractor's Name _License # �-.�l-- Installation will serve: Residence ❑ Apartment House�❑ Commercial)(Trailer Court '❑ Motel ❑Other --------------------------------------------- Number of living units_____________ Number of bedrooms ___--______Garbage Grinder- _________ Lot Size -------------------------------------------- Water Supply: Public System and name -------------------� -` 1----------------------------------------------------------------------------------Private Character of soi I to a depth of 3,eetj '5 nd'I]_Silt❑=� XC'aY ❑ Peat.❑ Sandy Loam -❑ Cay,Loam:❑ Hardpan ❑ Adobe.F! Fill Material ------------ If yes,type ---------------------------- k (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-•publ-ic sewer is available within 200 feet,} PACKAGE TREATMENT [ I SEPTIC TANK[ ] '" �` --- -------- - Liquid Depth ---______________________ Size_"_"='�-�---- ----:,----- - q P ` Capacit ------ Material______ "------- No.,-Compartments -----------=-----_--- Y ----------------- Type --= Distance to nearest: Well -- --------------- ----------------Foundation ....------------------ Prop. Line ---------- \ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------- '______.____ Total Length ------- ------------........ 'D' Box ------------ Type Filter Material -`-�-=i= -------Depth Filter Material ----------- ------------------•---- -• _ _-Property Line. -----------I------------ Distance to nearest:,-Wel.l-________:.___-_ ". `Foundation ___ --------------- p rty Diameter ______ti___- Number ---------------------- ----- Rock Filled Yes ❑ No � ' SEEPAGE PIT [ ] Depth ---------- -------- � Size Water Table Depth -_.___Rock Size __________________ _ - ----------- Distance to nearest: Weld"' -_ -----------��------- ---------Foundation ------_----------_-- Prop. Line -------•-------------- , .,Date ----------------- --- -1 REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------- 1 ___-__-.______.----------------- -- - -=--.�, .r . --------- ------------ -- ------------ -------------------------- - Septic-Tank (Specify Requirements) --------_--------------------- --- - - - # � kDisposal Field {Specify Requirements} __--- ` "`-- y F -,_,12�a - ----------------------- ----- ---------------------- ----------- ------- eluo_�_- ----------/_ (Draw existing anyrquired addition on reverse side) 1 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: t "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 -------------------- Owner - ---- ------------ BY - ------- Title - ---------------- - ._P---- (If of an owner) FOR DEPARTMENT 5E LY APPLICATION ACCEPTED BY ------------------- _ --. DATE ----�---,LG---IQ----------------------- -------------------------- ------ BUILDING PERMIT ISSUED ----------=------------ DATE - - ----------------- --- ----- -- ------- ---------------------- --- -- ADDITIONALCOMMENTS ----- ----------------------------------------- ---------------------------------------------- ------------------------------------------------ ------------ --------------------------------- ----- -------------------------------------------------------------------------------------- ------------------------------------------------I----------------------------- *------ ------ ------ ---- - - ---- Date Final Inspection by: -------- w _.. SAN, JOAQUIN LOC L ALTH j DIS R1CT ' E. H. 9 1-'68 Rev. 5M.