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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ._�_f - -------------------------------------------------------- This Permit Expires 1 Year From Date Issued __ ___ Date Issued ________ 7 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/LOCAAfTI .t� ----- /� c_ � _- -- - -CENSUS TRACT --•-------------.•---•---• Owner's Name [ .... G�7r✓___ j Phon _ �. Address _ �1�.3 .- -�+. +c� 1� City -� --------- Contractor's Name ___ ___s9Firs ________._.______.License # -� -r�d Phone Installation will serve: Residence partment House❑ Commercial ❑Trailer Court-,0 Motel ❑Other .----------------------------------------- Number of living units: ---- Number of rooms------Garbage Grinder ------------ Lot Size ------------------- Water Supply: Public System and name --------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loan1_1D__ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ SEPTIC TANK'{ I Size------------------------------------------------ Liquid Depth -------------------------- Capacity _____:_________,__ Type ----------------- Material_____________________ No. Compartments W f Distance to nearest: Well -------!'�--------------------------Foundation ---------------------- Prop. Line -----------------.-..- LEACHING LINE [ j No. of Lines ________________________ Length of each line--------------------- ------ Total Length -----------.---------------- V ___---_-_---. _'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------------------------------- i 4, Distance to nearest: Well ____________________ Foundation E..,.�.__r{__.___-__'-__ Property Line ---------_______________ SEEPAGE PIT [ ] Depth -------___---------- Diameter ---------------- Number ----------------------------- __________f_---.__._._----Rock Filled Yes ❑ No Water Table Depth --------------------------- _____________-- .___Rack-Size _____________ ________. ...... Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line _....---•------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------?!:`=,Dated-----------I -----_--.__.__-___-} Septic Tank (Specify Requirements)`----------------- ------�--------�----�--- ----------------------- ---- ------------------------------------- ----- ----•-- Dis sal Field (Specify Re irements) _ _1C -.--_ 6 rG¢rc __�•.r��____ _ G.r___-__ off.--. -�.--- - f " Q� --- ---------------------=- - ------ / --- ------- ------4P----- CJ_O-a L (Draw existing and required addition on rever 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 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 ---J ------------------------------------------------------- -- ---- - - ------------- ---- - (If other than owner) / FO PAATMENT USE ONLY APPLICATION ACCEPTED BY -- ------- ----- ------ ----------------. DATE ------�-5_ ---.7-1----------- -- ---------------- ------------------------ BUILDING PERMIT ISSUED -----------------r -- ------------DATE ------------_-----------__ ADDITIONALCOMMENTS ------------------------------------------------------------------------------ --------------------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- ----------------- ---------------------------------------- ------------------------------------------i------------------- ---------------------------------- ------------------------ --------------------------------------------------- - ` I Final Inspection by: ------------------ Gl!/ _ =--------------------- Date -J5__-� _�1 ------ SAN JOAQUIN L AL HEALTH_DISTRICT w , E. H. 9 1-'68 Rev. 5M