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-:FOLK OFFICE USE: --� x `APPLICATION, FOR SANITATION PERMIT --------------------- Permit No, (Complete in Triplicate) -------•----------- ------------ - -------- Date Issued ._--..- This Permit Expires 1 Year From Date Issued _ k Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 1 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: d -.- Q ` � 5 °� CENSUS TRACT ---- JOB ADDRESS/LOCAT ON 6,0 _-- -- -_p- f� ---------- ------------------------- ---- � �.. ----.Phone f �? ��------- ----- - --- --------------- ---- Owner's Name - - - ---------- -------- '--- ------------- Address ---- -------- ------------ ---------- - --- - - - - - - --- --- >p Cit C C --------------------------------------- Contractor's ---------------------`--------------- Address -_ 1.! -� --- ��- - ---��'_-�j�- �" ---------- ------- - -- Y ----- -------- ---------/ - y� --.License # �'S' ----- Phone Contractor's Name ��-�L�.��-_ "--- ----�----------- -�---- I Installation will serve: Residence P_;�'partment House❑ Commercial ❑Trailer Court l❑ j Motel ❑Other ---------------------------- --------------- Number of living units:---/_-.-.- Number of bedrooms -�--_--Garbage Grinder -A__-_ Lot Size ____-� __�• -------------------- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private QK , N.,. 'Character,of soil to a depth of 3 feet: Sand'V 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 see age pit permitted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT [ ] SEPTIC TANK:[ Size---/"Vvo-------------------------------- Liquid Depth --- --------------- Capacity !e0Oo--------- Type �P� i'1� Material---------------- - -- No. Compartments -------------- \D , r , Distance to nearest: Well -----�0------------------------Foundation ___/P------------- Prop. Line _----- -____-- W LEACHING LINE [ ] No. of Lines ------ --------- Length of each line-____- -------------- Total Length __l® -_-------.-.__ 'D' Box -./------- Type Filter Material 14-----Depth Filter Material ---- ---------------------------_ Distance,to nearest: Well ---- Foundation ----- ------ Property Line ------------------------ SEEPAGE --- -----_ -. - -- SEEPAGE PIT [ ] Depth -_6----------------- Diameter --------------- Number ------------.--_----------- Rock Filled Yes ❑ No Water Table Depth ------- -----------------------------------------Rock Size --------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------- -- -- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------`•- Date ----__--._----_---_-----_-_-----) Septic Tank (Specify Requirements) ------------------------------------ ------------------------------------------- ¢` Disposal Field (Specify Requirements). j -c'`'�------- �`' --------- ----------- kf --------- ----------- -------------------=------ ----- ------------------------------------------------------------------------------------------------------------------------------ ------- - (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 pensa ' nIa of California." ° . Signed " Owner BY -------------------------� )----- -- �/.J-- - -------------- �- -- Title --- Vic;=2T�' -..--------------------- ---------------- (If other owner) FOR DEPAR ENT USE ONLY APPLICATION ACCEPTED BY _ J -_Q----------------------------- ------------------------ --- ---- ------------- DATE ----- .'x_6----- ------------ BUILDINGPERMIT ISSUED ------------------ )---------------------------- -------------------------- ------------------------ --DATE .------- --------------------------------- ADDITIONAL COMMENTS ------- ---- ----- - ----------------------------------------------------------------------- -------- ------------------------------------------ ---------------------------- ---------- ------------------- ------ - -------------------- - ' ----- ------- Final Inspection by: ---------------------Date " ---------- ---------- - SAN JOAQUIN LOCAL HEALTH DISTRICT - E. H. 9 1-'68 Rev. 5M ;