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rOR OFFICE USE: APPLICATION FOR SANITATION PERMIT � -- ------- ----- - -------------- ------ Permit No.4_�".. "........ "U (Complete in Triplicate) -------------------------------------------------- � -------------------------------- This Permit Expires 1 Year From Date issued Date Issued UO 4,&_0Y =ti`s 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. JOB ADDRESS/LOCATION _Au �,%------r�C�_07_'�----+�_�---��_CY�,�-��.-CENSUS TRACT -------------------------- Owner's Name ----------------------- --------- ------Phone --------------------------------•--- � city ? 1 -) � � )- ---- 6) _ _ dContractor's Name _____ �Cl—_ 0, �y _ __y Installation will serve: Residence ❑ Apartment House-E] Commercial J� railer Court Motel ❑Other -------------------------------------------- Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size _ 4'I - f __-_____._-_- Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private" Character of soil to a depth of 3 feet: Sand'[' Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay 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 availa a within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ j Size----- ___00 _ _ Liquid Depth -------------------------- )(� Capacity Type --------------------- Material--------------------INo. 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 ________________._.___._ 1 SEEPAGE PIT [ ] Depth ------- Diameter __ Number _-_------------------------ Rock Filled Yes ❑ No i❑ Water Table Depth --------- ---------------------------- --------Rock Size ----------------------------- - Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------_-------- REPAIR/ADDITION(Prev.(Prev. Sanitation Permit# ----------------------------------------- -- Date --- ------------------------------ e L Septic Tank (Specify Requirements) ------�&-�--------�f�_�/1�-------- __ ( �------`;e_jZ 3 / �P Disposal Field (Specify Requirements) •------------------------------ s-- ---- ------------ ------------ --------------------------- ---- -` f ----------- -------- ----------- - x x - - - ----------------------------------------------------------------------- -- ----------- -------- {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." Signedt Owner i -------------------------- --------------------- Title (If other an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- - --------------. DATE ----------------__------- - ------------------------------------------------------------------ - ------------------ BUILDING PERMIT ISSUED -------------- --------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------- ----------------------------- ---------------------------------------------------------------------------=--------------------------- -- - ----------------------------------------------- ------------------------------------------------------------------ ------------------------------------------------------------------------- --- ------- ----------------------------------- --------------- ------- ----------------- ------- ------- ---------------= ----------------------------------- ------ ------ ------ - ------- Final Inspection b _ _ Date �_ SAN JOAQUIN LOCA HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M