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`;R.OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ Permit No. (Complete in Triplicate) - --------------------------------------------- -------------- This Permit Expires 1 Year from Date Issued Date Issued --- 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 exiting Rules and Regulations:,} t� JOB ADDRESS/LOCATION ------ : —---------- --------- ----CENSUS TRACT I Owner's Name ---------- &a-F..--------------sJS ±pte 4' - - Phone Address -------------------------------------- -- 0-7--------1_ 'L-_. City - --oar�e -- q Contractor's Name "� i ` = License # --------- Phone----------------- ------------------------------------------------ - i Installation will serve: Residence B�Xpartment House❑ Commercial :❑Trailer Court l❑ t Motel ❑Other ---------------------••--------------------- �� ' E Number of living units:._- _______ Number of bedrooms __:.Garbage Grinde /V't}_- Lot Size -_-__t_o- :_x_ _:o- _____________ { -- Water Supply: Public System and name __________ � e�-- # G. - - �!_C�C --------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'[:] Silt[:] Clay ❑ Peat E] Sandy Loam ❑ Clay Loam i❑ ;�Hardpan E':] Adobe [❑ Fill Material ---_______ If yes, type----------------------------- _ r (Pl'ot 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 pefmitted if public sewer is available within 200 feet,) )[`.► PACKAGE TREATMENT ] SEPTIC TANK;[] — -Size----------------------•------------------------- Liquid Depth ---------------------.----- L4 - Ca acit Type ____________________ Material---------------------- No. Compartments ----------- .......... Distance to .nearest: Well ------------------------------------Foundation __-____-___---___-_ Prop. Line ___._______1_________ `i . , LEACHING LINE [,,]/No. of Lines -_------t-------------- Length of each line---------iW ---------- Total Length _� --•----•---- k ------" ...... 'D' Box --— Type Filter Material _ _ _ Depth Filter Material _-_____ ----------------- 6 Distance to neare t. Well ___--N -_________ Foundation ________________________ Property Line ---------- SEEPAGE PIT [ ] Depth _._'_ ---------- Diameter ____________ _______ Rock Filled Yes E] No---- Number ----- -- -- -- - WaterTable Depth ---------'-------------------------------------Rock Size -------------------------------- Distance -------- ----------------------Distance to`nearest: Well _______________________________________Foundation -------------------- Prop. Line ----------- ...... REPAIR/ADDITION(Prev. Sanitation Permit# ________ ______________ � --------------------- Date --------- - -•-------------------) Septic (SpecifyRequirements) --- --------------------------------------------------------•---------------- Disposal Field (Specify Requirements] __________ ____/__ ` (/ ----------------- _ M ------- ---- - --------------------------------------- `� l' (Draw existing and required addition on reverse s4ei 4 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 ower or licen- sed agents signature certifies the following: certify that in the performance of the work for which this permit is issued, I shat) not employ any person in such manner as to become subject to Wor an's Compensation laws of-California." t Signe . Owner ------ Title _-_ =_- ---------------------------- -------- -------------------- (If other than owner).. F4 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ef --- -- DATE .......=- - - DATE BUILDING PERMIT ISSUED --------------------------- -- ------------------------------------ - ADDITIONAL r COMMENTS -------- ------------- - -------------------------------------------------------------- ---------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------•----- ----- ---------------------------------- --------------- a FinalInspection by: _ ----------L -------------------------------------------------------------------------------------- Date ------------ ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H, 9 1-'68 Rev. 5M � 4 ,