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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -ll ---------------------- ------------ -4_..4- ,v Permit No. _;_V-- -•- J ----- -------------------------------------- -------------- (Complete in Triplicate) ____________________ This Permit Expires 1 Year From Date Issued Date Issued -- ---- �d 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 ----- -- -4_ i_ -=- �� Q-------- �Q_-'CENSUS TRACT ----.5 -------------- Owner's Name - _S - _�. -AaG _UI TTL----------------- - Phone SfZ :-_Z3 Address --------- _ -•-----------•-- -----------------------------a`��-[p_----�•------ 1 � {rfl ---. City C✓ . ..c- f Contractor's Name - ---- .. -------^- .License # 2r7rC?"J.a 15-Phone ---------- Installation UInstallationwill serve: "Residence,'K Apartment House❑ Commercial []Trailer Court i❑ r` -_.--- Motel ❑Other`---------`�- ] Number, of living-units:_.--------- Number of bedrooms ______Garbage Grinder-_00-- --tot Size ----__--___�-�___- t'---:__--____ Private Water Supply:,•PLbkcSystem and name ------------------------'_------------v--------- ----------------- =---i------------------ --- ❑ Character of soilito-d'depth of 3 feet: Sand -Silt 0 Cl�ay� ❑ . Peat❑ Sandy Ldam ❑ Clay.Loam Hardpan • �'Adobe >. Fill Mterial ___---- __f If es,1 e ______________ _---------- a P ❑'` ❑ Y YP (plot plan, showing size of lot, location of system in relation to wells,' buildings, "4c. must be placed on reverse side.) ` NEW INSTALLATION: (No septic tank or seepage pit permitted if4u!�'Xf lic sewer?ts available within 200 feet,] PACKAGE TREATMENT [,�' °,,'SEPTIC TANK.. •-- ��Size__.-`" __ __ : _1Z_ __ - ---- Liquid Depth ____- Capacity,.1Z4Q_ fYPeµY�i�--Ltd- Ma nai---- 1 jNo. Compartments ------------------•--- I'` ---Foundation -_ 5'-- Distance. to nearest: Well ---- ---- -------------- -------__-- Prop. Line ---- --•-•- LEACHING LINE No 3'of Linesline _ __ Total Len �-- + Length of each line._____ d 9th` u� ''D' Box ---t- ------ Type Filter Material ---POck ____Depth Filter Material ----- __ ---------___________f__ a - a Distance to nearest: Well ,�___��`_-�________ Foundation ____ -&S-!----------- Property Line i SEEPAGE PIT.-,[ ] Depth --------------------- Diameter __- ;_________ Number -------- ------------------- Rock Filled Yes ❑ No f Water Table Depth ------------- �_ �_. ------ ----- Rock Size -__ Distance to nearest: Well ------ ------- --- ------f=oundation -------------------- Prop. Line -----------•---------• �• REPAIR/ADDITION(Prev. Sanitation Permit# -------------------= ---------------------- Date --------------------•-------------} Septic Tank (Specify Requirements) --------------------------r � I----------------------------------------------- f ---------------------- Disposal Field (Specify Requirements) ----------------------------------- -------------------------------------------------------------------------------------�- ----- 4 ------------------------------ { ------- --------------------------------------------- -------------------------------------------------- --------=--------------------------------- ------------------------------------- - i (Draw existing and required addition on reverse side) }' I hereby certify that 1 have prepared this application and that thekwiiork will be done in accordance with Safi 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: V "I certify that in the performance of the work for which this permit is issued;,I'shall not employ any person in such manners } as to become subject to Workman's Compensation laws of California." Signed -------------- ------ -------------------- --------- Owner J `r ' ---- Title ?*-tL I �------ (If other th owner) 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _____ ___ —!a --- - - ------ - �- - - -- -------------------------------------� DATE --------- ----- --- ------------- BUILDING PERMIT ISSUED ----------- - -------------------------------- ------------------------------ - - ----------------DATE --------- - ADDITIONAL COMMENTS ------- - ------------------------ --------------------------------- -------------------------------------- ----------------------------- ---------------------------------- ----- ------------------------------------ ---------------------------- ----------------------------------------------------------------------------------- - - ----------------------------------- ---- - -------- - - --------- ----- -------------------------------------------------------------- - - - Final Inspection by- - z� ---------------------------------------Date -------G- - _--- --- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M