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FOR OFFICE USE: r APPLICATION FOR SANITATION PERMIT , Permit No.------------------ ------------------------ No. ---- - {Complete in Triplicate) .......... ------------------ -------------- Date is I - ,, 'sued-�__�-Q-=2 2- ----------------------------- This Permit Exp ires I 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. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------- --- � 4151,--- - � T ''`" - _CENSUS TRACT Owner's Name --------------- � --�1--- -------------------------- Phone Address - ,�_4_'__4 -- -----`r -' f C 4 -.l c.��........ City ;x-- -2---------------------------------------------'------ -� • Contractor's Name -- ------- ----- � - ❑ ye-�____ __________License # -_ Phone _ Installation will serve: Residence AApartment House❑ Commercial : Trailer Court ❑ ' Motel ❑Other ------------------------------------------- Number of living units:----- .- Number of bedrooms ;7____-Garbage Grinder -_ ---.- Lot Size ----- ------------- Water Supply: Public System.and name ------------------------------------------------------------------ -----------------------------------------`__Privcite ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan`, Adobe❑_Fill Material ------------ If yes,type _____-__--_._ -__ - - s (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 TANKX' Size....... -1 ----------- Liquid Depth __._ -- ----__,..___ 0 .1, p ' Capacity/z c��'_�&,4 Type t,-e�G. Material---�2- -�t-= f nts ---�----.•------- l �No. Com artpe � ! Distance to nearest: Well ------_ --------------------foundation _ :_� ------------- Pro Line .-__ --- ----------- , LEACHING LINE r No. of Lines ------�-------------- Length of each line----- ............ Total Length', I 'D' Box .__ _`__ Type Filter Material _,aC� '_ _--.-_Depth Filter Material --___A--------------------------t. ,Distance to nearest: Well ___. _r___-_____ Foundation __l -f____------ Property Line ____ ____________SEEPAGE PIT Depth a ' ' _. �� ' r Yes No �� -------- Diameter '1 17--------- Number ------�- Rock Filled Water Table Depth ----------- Cj__�-------------------- Ro1-4 ck Size ----" -------------- -- f Distance to nearest: Well ----- _��----------------- ---Foundation ____C_ __._-__-- Prop Line __ - .._.__...____. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------•----) SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------- .--------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------:--------------------- -------- ----------------------------------------------------------------------=-------------------- ---•----------- 3 _ ---_- - --------------------------------- -.- 1 --------------------- ---------------=--- =---------------------- --------------------- ---------------- - - -------- - ---------------- (Draw existing and required addition on reverse side) T 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. Horne owner or licen- sed agents signature certifies the following: "1 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 ------- -- — Owner _ BY _W- s u Title . --------- - r - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------ ----------------- DATE b- ---------------- BUILDING PERMIT ISSUED ----------------- --------------------------------- -- ----------------------------------------------------DATE ----------- =------------------------------- ADDITIONALCOMMENTS ------------------------------------ ----------------------------------------------------------------------------------------- it ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----- --------------------------------- ---- -- --- ------------------------ - ----------------------------------------------------- ------------ --- ---- ------ Final Inspection by: _- _ _ ate �_ '-- --- -- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E_ H. 9 1-'68 Rev. 5M