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FOR OFFICE USE: - --- --- ----- ----- --------------------------------- APPLICATION FOR SANITATION PERMIT - Permit No: ..........I---------------------------------------- ---- (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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION -------------- - ___CENSUS TRACT _� 7-------------- Owner's Name ---/e?m ---69 ------------------------------------------------------------- ------------ Phone ------------------------- Address 7-7- f .�� - - ------------------------------------- City _ �!"� i'' / fi` :---------------- Contractor's Name ------ __. % __ 2_�s _. .._:__.License # ZS"5 Phone __ a Installation will serve: ResidenceAApartment House❑ Commercial:❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- _ Number of living units:... Number of bedrooms ------Garbage Grinder ------------ Lot Size _.__ -- ----y-_________ Water Supply: Public System and name ----------------------------------------------------------------------------------------------------•---------Privatex Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat ❑ Sandy Loam ❑ Clay Loam [] € Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ (J111 (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'[ ] Size------------------------------------------- ____ Liquid Depth -------------------- �xtS71�fj Capacity Type -------------------- Material---------------------- No. Compartments ---------__ ---------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------_---------- LEACHING --------_-----_.--LEACHING LINE [ ] No. of Lines --- ---------------- Length of each line___-.-�Q-------------- Total Length ---/- __--___-_-__ 'D' Box 6. ..e-Type Filter Material �� X_ ______Depth Filter Material ------zc --------------- Distance _____ _Distance to nearest: Well ---Aah-_-. . . Foundation _____/0____----------- Property Line ----�s--------------- SEEPAGE ___ __________SEEPAGE PIT [ ] Depth _ --------- Diameter! _- ______ Number -------�_-----'------ Rock Filled YesX No C Water Table Depth -----XTV-----------------------------------Rock Size ---------- i Distance to nearest: Well _____,l_��_� _.._________Foundation _.__/�__ Prop. Line ..-r ___�..__ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) 4t Septic Tank (Specify Requirements) ------------------ -- - ----------- - -- --- --- ---- - Disposal Field (Specify Requirements) _____ . �- ____I-=______:_ fC�!,�1____5�-!/`-- ____=____ t � - - - -- ----- ---------------------------------------- (Draw exi g 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. Homeowner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subjectork a 's Co ensa 'on laws of California." Signed ---------- ----- ------ 4/ [ �/ �' Owner By ------------------ ------------- --- ---- - -- ------- - -- Title 2- - ----------- (If other than o er - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ----- - ------------------------------------------------------ DATE _P_-47'.'-;? --------------. BUILDING PERMIT ISSUED ----------------- --------------------------------DATE -------- ---------------------------------- ADDITIONALCOMMENTS - ------------------------------------------------------------- ---------------- ----------------------------------------------------------------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- �._. Final Inspection by: -- --. -- -- 4------ - _ =' Date - -- Z---- -- - ---------- --------------------------------------------- ----- ----- - - ---------- --- -- - -------------- ----- -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M