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L FOR OFFICE USE:34i\ ►J APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ____._________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued _Z-_ __ ..7 z- 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 .-------ff d--- ----__�`------_- -------------- -------CENSUS TRACT Owner's Name /f ------ -------------------Phone Address ----------------------------- GL's- City --- ------- ---------------- - „i Contractor's Name ----------------- ' -_- -- --- - -- _____________ ---5 ---------License # _! - ��-_ Phone6_ef 607 )mtafttion will serve: 12Qsidence Ax+artmDnt�lo��sa Cnmmnrcfnl :pTr.,rle�r�� + Motel ❑ Other -----------------------------------•-------- r- g ' -- 3--..Gaf6age titin er c:-� {Q �� Number at living units:___________ Number of bedrooms �"' _ ________ �o� bize _.__5P _____ ____I_ ________________ Water Supply: Public System and name ------------------------------------ -------------------- -----------------._.....-----------'Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ SanAy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe tg4lPill 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 blit sewer is available within 200 feet,] I� PACKAGE TREATMENT { ] SEPTIC TANK D_ _ Size-----_-__._x__ -____-______--.________ Liquid Depth __��__.___--.______ Capacity/ � __ Type -90--e-7------ Material_ No. Compartments ---7�----------- D r � Distance to nearest: Well ____________________________________Foundation ____tQ_______-_ Prop. Line ----------- LEACHING _.___LEACHING LINE [ j No. of LinesLen g _.______ Total Length -- --�-�Ia th of each line-------------------- ---------------------------- l�R'4)tv 'D' Box ------------ Type Filter Material Depth Filter Material ---------le_`-.1....................... lFv Distance to nearest: Well ________________________ Foundation --14?__'—t-- Property Line -- ........ SEEPAGE PIT [ ] Depth --------------------- Diameter ---------------- Number ----- ------------- Rock Filled Yes No C] Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ________--_______-_-__ - REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) -------- ---------- ----------------------------------------------------------------------------------------------------------------- -•---- Disposal Field (Specify Requirements) ------------- ------------------------------------------------------------s-------------------------------------------- -------------------------- ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 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 become subject to Workman's Compensation laws of California." rl Signed ___. Owner - ---------- -------• By - - ---- - --- -- -- - - --- ------------- -Title -----------471---- --------- ----- ------------------- .- (I of er t owner] FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. ---- ---------- - --- ------------------------------------------------------ DATE --- 7. Z ---------- BUILDING PERMIT ISSUED ---------------- --------------DATE ----------------•-------------------------- . ADDITIONAL COMMENTS -------------------------------------- ---- - ------------------------------- --------------- --------------------------------L------------------------------------------------------------------------------------------------------------------------------------------------------------------------ � . Final inspection by_-------------------U _ y -------------- 8-- ¢ Date -- ---------------------& = (��/ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M w