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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Perm it No.. (Completwin Triplicate) ----------- ------------------ -------- ------------- �, Date Issued This Permit Expires 1 Year From Date Issued 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 exiiRsting Rules and Regulations: JOB ADDRESS/LOCATION ------------- ------ /Yl - -&E.61iO4.._CEENSUS TRACT .- r Owner's Name .- !' � �'G"�--------1-�Q ��--- _ Phone f� -----------•------ Contractor's Name License # _t, -a1f Phone -a�,V ,' d . Installation will serve:, Residence ❑Apartment House[] Commercial :❑Trailer Court Motel ❑ Other _.------------------------------------------ Number of living units:____/- - - Number of bedrooms -------_Garbage Grinder ------------ Lot Size -------------------------------------------- Water _-----_--------- -------------------------Water Supply: Public System and name ------------------------------ --------------------------------------------------------------------Private :i Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ 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.) NEW INSTALLATION: (No septic flank or seepage pit.permitted if public sewer is avail ble within 200 feet,) fflow{ 041 PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size--_-5- - -- '� Liquid Depth __-' - - ----------- /��G�1 Material------------------ No. Compartments ------ -_------ --• Capacity -�-�d-t?- - Type � � p �v � ... � Distance to nearest: Well ------------------------------------F ndat/n -/Z¢--- --- Prop, Line --- -------- Q Total Len v LEACHING LINE [ ] No. of Lines -----c2-------------- Length of each line-- _4 Length s 'D' Box ..__ Type Filter Material !11.6_Y4e��..Depth Filter Material ____- — ----------------------- ----- V► Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------------..-------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------------------ --- Rock Filled Yes [:] No ❑ �S Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------- ---------- REPAIR) ` ) ADDITION(Prev. Sanitation Permit# --------------------------------------------'Date -_-----_-_ ------------ -- -------- Septic Tank (Specify Requirements) ------------------- ---------------------------------------------------------•---•------- ----------•--------•._---------- ---------------- Disposal Field (Specify Requirements) --------- ------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------ - ------------------------------------------------------------ -. - ------------------• ------------------------ S F ------ •__--------.------ - - ---------------------- -------------- --------------------------------------------------------------------------------------- -------- -------- (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�a cordance 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 i as to become subje to orkrn Com ensation laws of California." r Signed ___- ' s - ----•----_ _._._ Owner By --------------- --=------ - ---------------------------------------------- Title ---- ----- --- ------------------------------------------------------- (if other than owner). �,... R FOR DEPART ME T USE ONLY APPLICATION ACCEPTED BY ----------- -------. DATE ------ -- -- - ----7 -- ---- --------- --------- ---------------------------- BUILDING PERMIT ISSUED --- ----------__�---_- _-_�_{_---_-__-. ------- DATE ----------------------------------- ADDITIONAL COMMENTS-- .-S --------1�--- ="= {iJcwr _ .7 $------ --- t ��------ ------ k -------------- ------------- -- - ------ ------------------------------------------------------------------------------------------------- ------ - ------ Final Inspection b v -------- -=-------------------- - ---- ---------Date f -. SAN JOA UIN LOCAL HEALTH DISTRICT i E- H. 9 1-'68 Rev. 5M