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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r4-5 S -- -------- � Permit No. _ ------------ iComplete in Triplicate) - --"-"---"-----"" ' ---------=----------------------------------------------- ____________________________________________________I This Permit Expires 1 Year From Date Issued Date Issued 7:7_7:7_74f_ t 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: I JOB ADDRESS/LOCATION ----- � ------------------- --CENSUS TRACT __.__________._..._.-. _. N A g--W Owner's Na/mee?X44.e "--&,,,d ------ hone Address /7 zw - --- � ------ --- Cit ---- ----- -- - - ----- --- -------- Contractor's - -.------ Contractor's Name a ------- License # Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other ----------------------------------•--- Number of living units.- ----- Number of bedrooms __.Garbage Grinder ------------ Lot Size,/�� Water Supply: Public System and name --------------------------------------------------------------------------------------------- -----------------Private / Character of soil to a depth of 3 feet: Sand❑ Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobes 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 [ ] 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 --------------------._.-__"-_--___________._ ' Distance to nearest: Well ________________________ Foundation ------------------------ Property Line__________________-_-___ SEEPAGE PIT [ ] Depth __________________ Diameter ---------------- Number ____________________________ Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size ----------------------- Distance to nearest: Well _______________________________________Foundation --------------------- Prop. Line ..................... REPAIR/ADDITION{Prey. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------_) Septic Tank (Specify Requirements) -------------- /�� -- ------- • Disposal Field (Specify Requirements) _ zi�----I ___ _ _____e�ewl�__L.e«� e s�____ __ • _ - --------_ -------- (Draw existing and requir 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: "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 bec e s =14 tq W ma Compensatior�l ws of California." Signed �� ----------- Owner By ------------------------------ !,ter ---------- Title + {If othe than owner) FOR DEPARTMENT USE NLY BUL DINGIOPERM PERMIT iSSUDEDBY- -" ---------------------------------------. DATE --- - -------- - -----------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------------------------------------------- ------•------------------------------------- ------------------------------------------------------ -------`---------'---------' ------------=---------------------------------------------------_ ti -�V - - Final Inspection by; --- --------- ------------------------------------- - - --__------------•----- - Date --- ------- -- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M