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4 1 r 4 �. ,;,.,FO Fft,E USE: # F I APPLICATION FOR SANITATION PERMIT _ .,: �. - - P N (' J ."(Complete in Triplicate) 71'- ------------------------------ -------------------------- I ----------- ---------------- - ------------------------ _ --------- --_---- 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .__d_-- _ �I---- ait,- ter- ---- %j� CENSUS TRACT ---- '_ ...._. .- Owner's Name 7� 1r1 / fe l =X9 0 —-------------------------------------- -------Phone._---� _�_/. �P f Address ---17-7p-`------ �s�c��z�� 2- - C� --- ------------ City $ ; -'' i 1 Contractor's Name , � � ---=--------=--------License # - S �.T�s'_ Phone t Installation will serve: Re' idence IV'Apartmen# House-F] Commercial ❑Trailer Court ❑ # I Motel ❑ Other ---------------------------=--------------- ff Number of living units:-'--'/ Number of bedrooms ___!_`_.Garbage Grinder --------- Lot SizevF£i -___ -� . Water Supply: Public System and name ------------------------------------ ----------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'❑ Fill Materia! ______._ _ If yes,type ________________ __ ____ � f {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 tankl r seepage pit permitted if public sewer is a ailable within 200 feet,) PACKAGE TREATMENT ] ] SEPTIC TAI, K'f ] 4 ' .1' .,Size------------------------ --------- ------------ Liquid Depth ------_------------.------ V v Capacity - ------7- -------- Type -------------------- Material-------- -------- ---- No. Compartments ---------_-- O i Distance to nec rest.. Well _____________________________te ------Foundatio ------------------=--- Prop. Line ------------------------ ! LEACHING LINE [ ] No. of Line's ___. -------------------- Length of each line-----------!------ --_._ ----_______-___---.-___-___. ____ Total Length I D' Box ----= Type Filter Material 4 ------Depth Filt r Material -----------------------------------------•.- Distance tonea est: Well ------------------------ Foundation __________ _____________ Property Line ------------------------ SEEPAGE PIT [ ] Depth ----- - _____ _____ Diameter ________________ Number __ -----.- ------------- Rock Filled Yes ❑ No 0 J WaterTable Depth ------------------------------------------------Rock Size - ------------------------------- Distance ------- •- ----Distance to ne t: Well ----------------------------------------Founclati Prop. Line -----.--_------------ REPAIR/ADDITION(Prev. Sanitation +Per �# -------------------------------------------- Date -------I--------------------- -___________________--_I SepticTank (Specify Requirements) -------------------------------------------------------------------- ------------•----------------------------_•---------------- ---------- Disposal Field (Specify Requirements) quirements) - -- _ `-•---- -------- � ----------! ------------------------------------------- ------------------------------------------------------------------------------------- U #(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: f "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner t as to becom b)ect t Workman's Compensation laws of California." r. Signed ------- ------- --- - = - ------ - � Owner Y '' ----- -- Title ----- (lf other than owner]; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ______�t_9-'�0 •------------------------------"--------"----- ----------- DATE ......577:S --1;;/----------- BUILDINGPERMIT ISSUED ------------- ------------------------------------------------------ -----------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS - - ----------------------------------- - ----••-I------------------------------------------------------------------------- -- --------------- ------------ ----------------- - - --------------------- ------------------- - ---- - ---------------------------------------------------------------------------------------- ii -- - - - --- ---- - Final insp � � - -- - ------ ate -. ----------- ----------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M