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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- (Completein Triplicate) Permit No. ._V--------- ---------- 9_._. ----------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to th 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. JOB ADDRESS/LOCATION �. - -5 ---. -------1__I- � --------------------CENSUS TRACT ----- -u�..__..... Owner's Name ----- ------ ----- --------------- ------- ----------------------.-------------- -/------------ ---Phone ----------•------•---•-------------- Address -------1 0_5 r?l------- A --- ------------------------- City -------/ ---- ------ ------------------------------------------- _ Contractor's Name ______ __ ____ (____ --------License # -i'p 3 -- Phone ------------------ ........... Installation will serve; Residence' Apartment House❑ Commercial ❑Trailer Court ;❑ p Motel ❑Other -------- --- - - 1 Number of living units:_--1------ Number of bedrooms _cam..-..Garbage Grinder ------------ Lot Size J j_OV__.___ -- Water Supply: Public System and name --------------------------------------------- ------------------------•--...------------•---------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam lay Loam ❑ 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 �c SizeLiquid Depth ___�'---_....... __._____ Capacity ____ _k___ -_,_ _ Type1lc. Material__ -b`L-- __ No. Compartments ... .... Distance to nearest: Well -----�_e___________ _____ t p. S�_.______ ? _ Foundation _______t_ti.________ Pro Line _____________ i LEACHING LINE [ No. of Lines ---------(------------- Length of each line__._._-1_-'L'p___1------ Total Length ______�._ '.p._..___._- 'D' Box's"__ Type Filter Material -----4L_f,---Depth Filter Material --------i_-1-k_'.................I--.___-_ Distance to nearest: Wel! ------, 0__t Foundation ------hp_t----------- Property Line _ _.-.-__.__._. i_ I & Depth _--_____- [#eteaeet�er Z _ ____ Number .______._1________________ Rock Filled Yes No ❑ Water Table Depth - -------------------------Rock Size ---- ------------------------ C Distance to nearest: Well ------------ ................Foundation {________ o_�___ Prop. Line ------�.r.._---__ REPAIR./ADDITION{Prev. Sanitation Permit# .. '_--..--_---------------- ---'--- Date-----------------------------------I SepticTank (Specify Requirements) ------------------ ----------=-----------------------------------------------------•-------------------- --------.---------------------------- Disposal Field (Specify Requirements) ----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 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." ; Signed -------------------------- ------------------------ Owner By ------------------------------------------------------------ -�------------_-�-. Title -- --------------------------------- - (If other than owner) FOR DEPARTMENT USE ONLY � APPLICATION ACCEPTED BY --- -- ---- - - - - - -- - -- - --------------------- ------------------------------------------------------. DATE ---------------- BUILDING PERMIT ISSUED -------------------------------------------------------------- ----- ----------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ---------------------------- -- - ------------------------------------------------------------------------------- ---- - ------------—----------------- ----------------------- ------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------------------- ------------ --------------- ----- - - ----------------------------- -------- -- -- - -- Final Inspection by: - ------------ ---------------- ---------------•-------------------------------------- - Dote / - SAN JOAQUIN LOCAL HEALTH DISTRICT f,/ E. H. 9 1-'68 Rev. 5M