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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT; y Permit No. ----TX-:-=5----- (Complete in:Triplicatel. , _. F , . .� _ ---------- -------------c•---- �- . Date issued This Permit Expires E.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 existing Rules and Regulations: J r , ' �� = CENSUS TRACT ------ ------•----------- JOB ADDRESS/LOCATION " C/_�C, l�-'--- �- �•� v one Owner's Name .-- / /1e,A --------�------------------------------------•---------------------------------- city S � n� 1.� r---- ...._ - ---- - - ---------- --- Address / =/ _ - `�'- �Phon ` Contractor's Name f -t t-G � ' -------.License # P,7- ..- e VY1"`%tf y� - Installation will serve: Residence TKApartment House�❑ Commercial;❑Trailer Courta "❑ Motel ❑ Other ......................................... -- --------- --------- ------------=' Number-of living units:-J------- Number of bedrooms Grinder ------- --'_ Lot Size --------------------------------------------- -Z v (� Water Supply: Public System and name ------------------------------------ s a . -----------------------Private 5ZCharacter of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 71 .(� 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 tank or seepage pit permitted if public sewer is available within 200 feet,) (� �PACKAGE TREATMENT ( ] SEPTIC TANK [f Size-------------------------- --------------------- Liquid Depth ---------'-•-------- Capacity -- Type -------------------- Material------------------------ No. -Compartments ------ •---- Distance to nearest:. Well ------------------------------------Foundation -------- '-=--•-•-------------- Prop. Line -----'--- -- --------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------------- ------ Total Length ------------- ------- 'D' Box ------------ Type Filter Material -_-----------------Depth Filter Material --------------------•-------!i" ------------ f Qistance to nearest: Well ------------- -_-__- Foundation Property Line :-_---_-_--._-:_--._-•-- E i Depth Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 1❑ SEEPAGE PIT [ ) P ----------- ` Water Table Depth ------------------------------------------------Rock Size ------------------------- ------ Distance to nearest: Well ----___-___----- ------Foundation -------------------- Prop. Line ---------------------• o ' REPAIR/ADDITION(Prey. Sanitation Permit# •------------------------------------------- Date -----------------.----------------) - ...... -- � ----- �r111--- ------------------"- .- -------------------------- Septic Tank {Specify Requirements) ------ sDisposal `Field (Specify' Requirements) --------------- ---- ---- --------------------------------------------- =-------------------------------------------------------------------------------------------------- ----- ------------------------------------------------------------------- ------------------------- ----------------------------------- ----------------------------------------------------- - t I (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 liven-. r sed agents signature certifies the following: 1 t "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 ------------- ------------- -------- - ---------------- ------------ (If other than owner) FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY ---------- --- --- ---®. DATE ..-�_ -3l__JAS'-----•----- ' BUILDING PERMIT ISSUED ------------------------------- ---------------------- ---------------------------DATE _. ADDITIONALCOMMENTS --------------------------------- --------------------------------------- ---- --------------- ------- ------- ------- ------------------------------------------------ -- - -- -- ---------•------- Final Inspection b ��----`- ------------- -------------------•------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 'r F H q 1-'68 Rev. 5M