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Y FOR 1,bfFICE USE: APPLICATION FOR SANITATION PERMIT -- ------------------------------------------ 1! ------------------------- Permit No: _.�Z--~-�- ---------------------- ---------- - -- ,i (Complete in Triplicate) Date Issued __- ;-I __ ' _ This Permit Expires 1 Year From Date issued �l Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATION .0 y.....� '� � �'�?---------------------- ----CENSUS TRACT II ------------------------------------Phone ------------ ----------------- Owner's Name .---J1-- Address r ;,l"j_ - >) - ---• ------------------------------- City - ------------- { Contractor's l --License # ------- -;-------------- Phone ------------------- Name /J am----- -------------------- Installation will serve: Residence IM Apartment House,❑ Commercial :❑Trailer Court ;❑ I. l Motel ❑ Other -------------------------------------------- t Number of living units:_-------.- Number of bedrooms ________Garbage Grinder'��.i___ Lot Size _--- ------------------- Water Supply: Public System and name -------------------- - -------------------- Private ] Character of`soil to a depth of 3 feet: Sand❑ Silt ElClay E] Peat[DSandy Loam ] Clay Loam ❑� T 0 .. � - li Hardpan ❑ Adobe ❑ Fill Material _____ ------ yes,____ if , typ e ---------------------------- (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 public sewer is available within 200 feet,) f f Q PACKAGE TREATMENT { ] SEPTIC TANK jk] Size___i' /_&-- -- ----- ---- ------- Liquid Depth. - " --------------- Ca -------------- Capacity/� --------- Type _y Material___��-r -------- No. Compartments ;�-�----------------- -- / — ---Foundation --J4-'_---- """"" Pro Line _A-0-------------- . Distance to nearest: Well 1�9----------------------------- p• LEACHING LINE No. of Lines __3-------------------- Length of each line--. ------------------ Total Length _ - -b___._-_____---__ I r 'D' Box °- --- Type Filter Material AO1,A----------- Filter Material __/-I-------------------------------------- I: Distance to nearest: Well -- --------------- Foundation ---------------- Property Line, ---------------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes E] No WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance ----------- ------------------ Distance io nearest: Well-----------------------------------------Foundation -------------------- Prop. Line ..--------.-----_--- REPAIR/AD ' DITION(Prev. Sanitation Permit# --------------------------------------------- Date --------------------------- ------- Septic Ta ----------------------------•---- p Tank (Specify Requirements) - --------------------------- -------------- ---------------------------- ------- --------------------- Disposal Field (Specify Requirements) --------------- ----------------------------------------------•------------------ II x ----------- _ -J}---- ------ "".-- --�'n-'-c" -- -..... ..r---- '- -- ---- '=---------------------------- - --------- -- ----- ------- ------ ----- �- (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: "I certify that in the performance of the k for which this permit is issued, I shall not employ any person in such manner as to becom t to Workman's en ati.on laws of California." Signedte "' _ Owner 'I------------------------------ i Title ----------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _, �R+ - ------------------------- ------- DATE . BUILDING PERMIT ISSUED ---------'--------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------- "_------------------------------------------------------------------------------------------------------------------ ___ ------------- - ---- ------------------------------ - ----------- - --- - ------ --------------------------------------------------------------------------- ----- ------- ---------- ------------------- - - ------ ------------- ------------------ � . -------------- b - ®----iy ------.Date - --Final Inspection SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 ��'l'-'68 Rev. 5M _ - -