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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT - - - -----_ - ` I Permit No. - //�f,, (Complete in Triplicate)........[....------- -----------.- ----- Date Issued - ..'-Z._z.7 L -------------__-_-.-__,_-___.__-___.__.-- - , This Permit Expires 1 Year From 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. 549 and existing Rules and Regulations: q�72 E �y 6 .... .. . JOB ADDRESS/LOCATION ._. .... ...--_ .. i-._--------------- -------- -_._- .Y-__.---- ..-_._._-.__CENSUS TRACT -.- �AG✓� G13� � .... Owner's Name p� Phone . Address ( ---«::... --'"----------_.......... City ----------- ........-.......... Contractor's Name ............. ------ ---- ---- ....License # _ ---- -------.-- ----- Phone .----_--------- --. Installation will serve: Residence ❑Apartment HHoouase F] Commercial ❑Trailer Court F] Motel Other_....l.l:�c 'f-lr--!!/ :_.._...... Number of living units:.____.. Number of bedrooms 3..___Garbage Grin/der _-___... Lot Size ..._._...... ....... ...�..j......__......_ Water Supply: Public System and name _---_.?/E'l l.Y:�,rt-�- U' 'frz-"-'J-- ---------------------------------• ----- -Private ❑ Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam D Hardpan ❑ Adobe F] Fill Material -...-------- If yes,type---------------------- -_-. (Piot 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,eis_Uailable within 200 feet,) /r \ PACKAGE TREATMENT M SEPTICTANK{ ] Size ........ Liquid Depth --------- \ Capacity, '_�----- 14ype ...._.--.--_-. Material�i.�0_.vt4C(( No. Compartments .4............... f / Distance to nearest: Well _. .'�........................Found ' -.��_.._..-_- Prop. Line __ _ QX LEACHING LINE No. of Lines .__.--�.-....._. Length of each line_- -_._._ Total Length .-. l.........._.._...... 'D' Box -.-I-.-__ Type Filter Materi 1 .,rQB.GLb.—:_Depth Filter Distance to nearest: Well p. ..._.._. Foundation lv.f_..__..--._ Property Line�� I I SEEPAGE PIT' - Depth ........ ---- Diameter Number ---------------------------- Rock Filled Yes ❑ No I34' Water Table Depth -------------------------------------------Rock Size .--------------------------- Distance to nearest: Well ------ ..........................._..-Foundation --------_---------- Prop. Line ..................._- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ..... .......... Date ._._............---...--------__.) SepticTank (Specify Requirements) -.--------------------------------------------------...........................--............----------------- ...................... Disposal Field (Specify Requirementsl ........ - --------------------------- ... --------- - ------ --- --- --..._ _ -------------- ------------- --- - - ---- --- ----------- (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 .._------v-------------- --------------- ....... ---------------------_--.-..........-- Owner By --- ---------------- ---------------------------- - Title ..... - - _... . . ..._...... --------- (If other than owner) R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- --- - ----------------------.... ........---------- ----- _ DATE -.._.--. ...Z,.j.-� BUILDINGPERMIT ISSUED -------------------------------------------- . ....................... .DATE . -------------------------- ----- ADDITIONAL COMMENTS --------------------------------- --------------- ---------------------------.--------------------.--- ----- ---......)_. .•-----------_-----------------------.-..'--------------------------------------------.............--------------------- r FinalInspection by, ------- ---' --' ��J-----------.............. ------.....__..._-__..._.__.Date ......... -- .......... SAN/JOAQUIN LOCAL HEALTH DISTRICT v l: E. H. 9 1-'68 Rev. 5M