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FOR OFFICE USE: t 3n APPLICATION FOR SANITATION PERMIT -- �; � ---------- --- ---------------- Permit No. U 4 .. (Complete in Triplicate) I' This Permit Expires 1 Year From Date Issued ` Date Issued 7 --- --------------------------- 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 compliancewith u ty Ordinance o. 549 and existing Rules and Regulations: JOB ADDRESS/LOCk10N J ------------ --- --e CENSUS TRACT e Owner's.Name ----- ---------- _f�---� f--J ----------------------------------------- Phone ------------------------------------ Address ------------------- --- - ---------------------------------------------------. City, ® ----------------------------------------- Contractor's Name ._ --------------- ---------------- --- ----------License # ------------ ------------ Phone Installation will serv_e: Residence ❑ Apartment jHouse❑ Commercial:❑Trailer Court ;❑ t; Motel Other _.__ Number of living units:----- Number of bedrooms ----j______Garbage Grinder,llfd____ Lot Size .L'/_C_-I- "----------------------- - Water Supply: Public System and name --------- ------------------------- --=-------- ------Private Character of soil to aldepth of 3 feet: 5 nd`❑ milt-�]-brclaiy ❑ Peat❑ Sandy Loam Clay Loam [] Hardpan ❑ Adobe EJ Material IV __ If yes, type ---------------------------- : (Plot plan, showing size of lotpll,ocation of system in relation! to wells, buildings, .etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ P7IiC TANK - Size------ ------ --------- Liquid Depth ------.----- .. - � Capacity, _- ��0-- -- TYpe --- t _�Mafierial- ------- No. Compartments ------ --------- --- 1 �Dis arnce to nearest: Well ------ -----------------Foundation _../_.0--__-----___ Prop. Line _ 1 1 (es ---__---_____ Length of each line_ .__. ." _7_�_.__ Total Length Q LEACHING LINE f No. of .Lin J k' - , ��___ ___ t f D Box �/ _. Type Filter Material 1_/ �_ --Depth Filter Material - __�_�_�_____._ 111 ----•--•---•--------•- Distance to nearest: Well ... -"Foundation ndaon _._ .0__�.________ Property Line ................ SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- 0- Depth ---------------------------- Rock Filled Yes ❑ No l❑ Water Table Depth ,.Bock Size -------------------------------- r Distance to nearest: Well ---------------------------• --- 'Foundation -------------------- Prop. Line _...---.__..--.-.----- REPAIRyADDITION(Prev. Sanitation Permit# ------------------------ -------- Date -__ __) Septic Tank (Specify Requirements)''""'-_-""" � t P Disposal Field (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•--------------- ----------------------- ------------------------------ -- ---------------•---------------------- - ---------i------- ----------------------- --------- .- ---- - - -- ------------------------------------ ----- ---------- ----- - -- "' ► (Draw existing and required addition on reverse side) y I hereby certify,that I have prepared this oppl ation and that the work will'Zbe.•done in�actiDrdrance with,5an Joaquin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Florae oZer or licern sed agents sign�ture certifies the following: "I certify that in_the.perforrnance,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 ------- ---- -----------------------------I---------------------------------------------------- Owner BY --------------- — - -- ------ Title ---------------- (If her than owner) Y 4A. FOR ENT USE ONLY VPLICATION ACCEPTED. BY - '4-- ------- ---------------------------------------- ------ E- DAT ----------------- .B*JILDING PERMIT ISSUEb -- -- --------------------------------- -------------------------------------------------- ------------DATE ------ ----- ADDITIONAL COMMENTS .---------- -)-' i -- I i. ----------- ---- ------------------------------------------------------ ----------------------------------- ---------------------------------------------- ---------------------- - ----------------------- -- ---- -- - - -------------- - Final Inspection b ;_ l -- p Y� �-------- -- ---- --� -- - - ------- - --- - --••--- - - - -- - - - - ----------------.Date -�'.-.._Z7•-_1�:_------- - - - - - -- - -- - - - - - - - - - ---------- I r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ."� ,a'�.% - u'