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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ------------------------ ---------------------• Date Issued - ' j This Permit Expires 1 Year From Date Issued v Application -- 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: " ------CENSUS TRACT __- -------------•- -------------Phone --------------------------------- JOB ADDRESS/LOCATION - "T-�_��_� --- -+G�.--- - -�- ----------- Owner's Name ---------- -- -------------- --- - ------------------------------ --- 1 rJ �.._. City _ Address ----------- - ---'3 I, _ - -- -.License # -��_�_. Phone ------------------------------ Contractor's Name ----- p41. a ' ent House❑ Commercial ❑Tra ❑ iler Court ', Installation will serve: Resident Motel 0 Other ---------------------------•---------------- Number of living units------ _----- Number of bedrooms __. ------Garbage Grinder ------------ Lot Size __ ' - - Water Supply: Public System and name ----------------------- Private - -------------------- E Character of soil to a depth of 3 feet: Sand'E] Silt Q- Clay E) Peat ElSandy Loam ❑ Clay Loam.E] Hardpan Adobe:❑ Fill Material...--------- If yes,type ---------------------------- (Plot plan, showing size of lot, location of system in-relation to.wells,_buildings, etc. must be placed on reverse side.) it permitted if public sewer is available within 200 feet,) O t NEW INSTALLATION: (No septic tank or s�ge p' pA " P/ � i k PACKAGE TREATMENT [ ] SEPTIC TANK'[ "Sze_ ___ _ _ Liquid Depth __ ________________ '- - - .._ p ------ - = c CapacityA;200_ Type - ------------ --- Material= - No. Com artments o r -Foundation ----- a------------ Prop. Line ---•-- Distance to nea st: Well --------------=��--- I ' ,ra Total Len th __�_a --------------- LEACHING LINE [ No. of-Lines ___-_ - Len th of each line___ - g -- �+ 'D' Box _-- -- - - Type Filter Material ------'-_ --- -----.Depth Filter Material ----��-----------------------------•-•--- `-------�p-.-- ----- Property Line. 'S Distance to nearest: Well __.____��__--:-_-_.__ Foundation P S � '�__ Number ------ _.�------------- Rock Filled Yes � No SEEPAGE PIT [� Depth �---- ----------- Diameter _-___-_ �� Water Table Depth ----------------- �--------------------------RockSize -- �-�--3-------------- Distance to nearest: Well _____________`_Loo--'--_--•_;_:---Foundation ------t-tJ--------- Prop. Line - ----_..-_--__--•- REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------------------) - ..: ---------•--- Septic Tank (Specify Requirements) ------------------------- -------- -----:---------- Disposal Field (Specify Requirements) ----------- ----- --------------------------------- ----------- �- '(Draw existing and required addition on reverse side) u ---�- 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 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 -------------- ------ --------"-- IoLll� Title ------ ---------------- ----------- ---------------------------- - ---------------- ---------- - ----- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _::.. -------------------- DATE -' 7 d = ' BUILDINGPERMIT ISSUED ----- i---------------------------------------------------------------------------------------------------DATE --------------------------------/--------- ADDITIONAL COMMENTS ---- -I-------- --------------------------------- ----------- ------------------ - ----------- - -- ------------------•--------------------•-- - --------------------------------------------------------------- ___^_____1• .._--__-_-_________________________________________________________________.___._-____________-__ -_____,__.________ ----------- ---- __--__- -4_._ __ ----------- 1;4011 .._._____ -.___._ --------------------------- _ _ j __ Final Inspection b ------------DaterY '-21--�- p y :,� -- - --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.