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_ 1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------ --------------------------------------------------- -( (Complete in Triplicate) Permit No. ------- ---------------- ------------------- Date Issued ----------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and installthe work herein 4 described. This application is made in compliance with County Ordina ce No.'549 and existing Rules egu atioin: JOB,ADDRESS/LOCATION .- ___.__- ------ - - CENSUS TR T �_ - ��- �-----------------------:------------•t- ------ --------Phone -------------------------------- Owner's Name _- -------- --- --- Address `s q ---- - k City -------------- 1 - License # -G - Ph ne Contractor's Name ------- -+ Installation will serve: Residence partment House❑ Commercial:❑Trailer Court i❑ Motel ❑Other ------r-�--�----------------------------- = t Number of living units:------ -__ Number of bedrooms O`�____Garbage Grin'l er ----------- Lot,Size ------------------- am ______________ -- Private I Character of soil to a depth of 3 feet: Sand'❑ Silt-.T.....�.Cla. - �at Sand Loam • C-la'Lo _ a Water Supply: Public System an name --- -------------- ---- p ❑ y ❑ Y d❑� Y am .❑ , Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -------------------- (Plot -----------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed' on. reverse side.) f ' v , NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth :_______.._-_---- Capacity --------------------- Type -------------------- Material---------------------- No. Compartments -----------•-----= LEACHING LINE [ ] No. of Lines ------------- -- -------------gth of each IineFoundatio�------ - . 'Total Lenoth iLine�--___._________.._-- Distance to nearest: Well P• y Len 9 _--- r D' Box ------ ----- Type Filte _ yp f 'r Material --------------------Depth Filter Material ------------_- ------_..---------------•---- : Distance to nearest: Well __------------------__ Foundation ____-- -_ _�. Property Lige ---- _._--__--___._ ---- SE=EPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------- led .yes © No .i[] F -----Rock Size ------- ------------------------- Distance ---- -------------- --, Rock F.iI Water Table Depth --_-_-_-___. Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... ,REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------------------1 f Septic Tank (Specify Requirements) ------------ --------------------------- --------------------------- Disposal Field (Specify Requirements �'�� ---- ----- --------------------------- i --- -'-'-- Y- -- -- - -- -- - -------- - - - ------ -- - ------- ------------------------------------------- ------------- -- ------------------------------ --------------------- _. ,(DrmV eexpspting and required addition on reverse side) _T I hereby certify that I have prepared this a licafiion 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: f 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 Cbmpensati.on laws of California." l : Signed --- -------- Owner , / f By ------ -- ----------- 7itl ----- �/ . (If other than owner) FOR DEPARTMENT SE ONLY // /� ----- ------------- ------------------------- DATE - ---6'(o--------------------- APPLhCATION ACCEPTED BY :- -- -_ -_ ---- --- - - i BUILDING PERMIT ISSUED -------------------------- --------------------------------DATE ------------'------------------------------- - ----------------------------- -- ADDITIONALCOMMENTS --------------------------------------------------------- ------------------------------------------------------------------------=-----•-------------------- ------------ ------------------------------------------- ------------------------------ ------------------------------ --------------- ------------------------------------------------------- n -- - ---------- i Final Inspection by: ----------------------------------------------- --------- - Dat -- ------ ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 T-'68 Rev. 5M