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%FOR OFFICE USE: - ,, APPLICATION FOR SANITATION PERMIT � (Complete in Triplicate) Permit No. - ------------------------------------------ ____ This Permit Expires ] Year From Date Issued Date Issued k 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATIO i _ 7- -- ------------------------------------CENSUS TRACT --------------------•-- f Owner's Name -- -----Phone.IiZ_"_ _�.�' / • Address --- ---------------- ------- City Contractor's Name -------------- --------------------------.License # 106411------ Phone 59'&-x_607 _ Installation will serve: Residence Apartment House-F] Commercial oTraiier Court �] Motel ❑Other Number of living units: _ Number of bedrooms ---- ___Garbage Grinder ___ _ Lot Size -------------- /Z-- -_ ----------- Water Supply: Public System and name ----------------------_--------------__ --------- 41-t ----- - -----•-------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt fl Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.F1 Hardpan ❑ Adobe 'j] Fill Material ------------ If yes,type ___________________------_ (Plot plan, showing size of lot, location of system in relation for 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,l I PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size______________________ ------------------------------------------------ Liquid Depth --- - -------•-------•--- Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ---------- Distance --------Distance to nearest: Well ------------------------------------Foundation ------ ------------ Prop. Line ---------------...... ' LEACHING LINE [ ] No. of Lines ----- -------- Leng of each line---- --------------------- Notal 1 Length ------ .------------------. 'D' Box ---------.-- Type Filter Material ________________Depth Filter Material `_ . s .__ _ Distance to naarest: We'll -------------------- Foundation' --------R______________ Pr6pert�Line ------------------•--•-- SEEPAGE PIT ( ] Depth ______________V__- Diameter _____-_____L-�NumberI-----_________ Rock Filled Yes ❑ No 0 Water Table-Depth___I i j ' ___._ Rock Size___ ± 1 ( i! - Distance to nearest: Well - ---------------------------------------Fou tion -------------------- Prop. Line—:.---- ----•-- t REPAIR/ADDITION(Prev. Sanitation Permit # __ _ __________ ------------------------- Date;,___-n- - - } �� ='------- SepSe tic Tank (Specify Re uiremen'ts _--- -------.------ ------------------- P I P Y q M -- 1 4 Disposal Field (Specify Requirements)`�_�_•______ .- F - - --- ---- - --------------- -------------- } 3 - __- k - - I p -------------------------------------------- -Drawexiipin9and reqd a uireddition on revers e t- side) i I hereby certify that 1 have prepared this a lication ahc!"that'the'"wo�lz—wiFll"be done in accordance with San Joaquin County Ordinances, State Latins, and Rules and Regulations of the San�Joaq`uin`!a of Hearth District. Home owner or liven- sed agents signature certifies the following: a „ 1 i "I certify that in the performance of the work for which this p� errnit+issued;I shall not employ any person i such manner as to become subject to Workman's Compensation laws of California." 1. { i Signed ------------------------ Owner ), ' BY ------------------------ title t -------- ' (Ifo er th owner. --- --------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- --- Q ✓ � '- DATE _/1—S'_ BUILDING PERMIT ISSUED --------------' _ -__ - ADDITIONAL COMMENTS ------- - ; ------------------ -J1 Ai, �t�N- ------ -----DATE ------------------------- ------ ------ ------ -- ---------- -- - -- -------------1�' �� ,1�{� ----------------------- ------------------------------ - ---------------- - - ----- ---- ' --------------------------------Final Inspection by-. -------t-------- _ -- - -------- - ----------- -------------- --Dae ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M t