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ICOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------- --------------- -- ''G F ' {Complete in Triplicate) Permit No. _l. _---.---.---_--- ---------------------------------------- This Permit Expires 1 Year From Date Issued Date IssuedO--�� 5 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: JOJADDRESS/LOCATION .-_- - G--d-.--- 4j - --------------------CENSUS TRACT --------------............ Owner's Name f----- e'= --- ------------------------------ �_..__P_hone� Address / f- G ¢ --------- City . 6 " Contractor's Name ------ �r:+. — . -- - ------.License X�X/' fi .7 Phone/? °?.---------jl tj InstaIIlation will serve: Residenceopartment House❑ Commercial :❑Trailer Court !❑ Motel ❑Other _�------------------------------------------ - ------------------------ j r Number of living units:_.______ Number of be rooms --,_____Garbage Grinder _.__ Lot Size __ -_�__f_ Water Supply: Public System and name ---------------------------------------------------------------------------.Private ❑ Character of soil toadepth of 3 feet: Sand'❑ Sift❑ Clay ❑..,..Peat❑ Sandy Loam .E] Clay Loam 4 Hardpan ❑ Adobe Fill Material --------�_)If yes,type -----_______________ Lj iPlot:plan, showing size of lot, location of system in relation towells, buildings, etcmust be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) [ ] ,(,, fs1 f PACKAGE TREATMENT SEPTIC TANK Size __ " __-.,?L___t_.LP______ Liquid Depth ---- ________________ Capacity_— O 4a �fType [._ Material._ i - - No. Compartments -- =_____.:_.__ yDistance to nearest: Well ------t _ -------______----Foundation _______ Prop. Line ____G=___r_______ LEACHING LINE f No. of Lines __._ ______________ Length of each line------ R .......... Total Length _- I o D' Box ___tr....... Type Filter Material __/l _Depth Filter Material ____-111� ----------------_---_------ Distance ------__________--- ....__-_Distance to nearest: Well ----%5`4'f-------- Foundation ___ 4- _______ Property Line ----- ......... F' - Rock Filled Yes ( ` No SEEPAGE PIT �"` Depth __�_�._______ Diameter 3_�-_.______. Number ._____�_____________ e. Water Table Depth -------��---- ____________________________Rock Size --_--- __r --------------- 1 Distance to nearest: Well ----/0-_fi_-____________________Foundation ------- ------------ Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- Date ---------------------------------_j Septic Tank (Specify,,Requirements) -------------------_5- bisposal Field (Specify Requirements) ____________ -------- ----------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- ---------------- ---------------------------------------------------------- ' -------------------------------- ----- I---------------------- - ------------- ---- - s {Draw existing and requiredadditiori-on reverse side) I hereby certify that I have prepared this application and that the i work will be done in accordance with San Joaquin Coun,ty,Ordinances, State Laws, and Rules and Regulations of the-S n 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 peimit is issued,.) shall not employ any person in such manner as'to:become subject to Workman's Compensation laws of California:'-.'- ` -•- -.- Signed --- ----------------- ----------- -� : ------ Owner -------------- - - --- Y�------------------ t! - Title - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.r��_A______ �_.Y -2--�-�-----------------------------------`-------. DATE _�.17_,2-_-.d-- ----- / - - ---- ---- ----�`---- BUILDING PERMIT ISSUED ----------------------------- ------------------?_.-------------------r_--I---------DATE -------------- ----------------------•---- ADDITIONALCOMMENTS -----------------------------------------------------------------------`---------------------------------------------------------=----------•---------------- %---------------------------------------------------------------------------------------------------------- --------------------'----------------------------,----------------------------------- I 'Es ----- ------------------ ---- ---•- Finalf'Inspection by: --------------------------------------------------------- ' ----------------- I-------- Date ----- ------ ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1.9 1-'68 Rev. 5M I