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FOR OFFICE USE: r r5 F M APPLICATION FOR SANITATION PERMIT --- ------------------- :s _ (Complete in Triplicate) Permit No. --------------------------------------------------- _ ____________ This Permit Expires 1 Year From Date Issued Date Issued --g'_ �___ 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: JOB ADDRESS/LOCATION ;tea-'�--------g? _-_ � -P� --------------------------- ---------CENSUS TRACT Owner's Name �--------_� (.*� `'-- - f-- - - -:"__ = =- - -- --- --------Phone..-��'►�:, �i! -- --------------- ----------- -- - _ - - Address - �./I! city -- :=.��` - - �' ----- ---------------- Contractor's Nam "V!.-._ �ct +�__c�{- __-License #;-�' /f--_-- Phone - rr <®7_ Installation will serve: Residence Apartment House'❑ Commercial ❑Trailer Court ;❑ Motel ❑Other Number of Living units:----/----- Number of bedrooms ___:77_-Garbage Grinder ------------ Lot Size -----------------_----------------_-- .-_- Water Supply: Public System and name -----____----------------- ---------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ r 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-seepage pit permitted if public sewer is available within 200 feet,) '\ PACKAGE TREATMENT[ ]'',,SEPTIC TANK'[ ]= Size---------------------------------- ------------ Liquid Depth Capacity''----- -------- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well --------------------------------•---Foundation ---------------------- Prop. Line ---------------------- V LEACHING LINE [ j No. of Lines ---_---_-____------ Length of each line---------------------------- Total Length .--------------------------- a 'D' Box .----------- Type; Filter Material ------------------- Depth Filter Material -------------------- ------------------------ # Distance to nearest: Well ------------------------ Foundation ---------------------___ Property Line SEEPAGE PIT [ ] ; Depth - Diameter __------------- Number _--------______ _--___--_ Rock Filled Yes ❑ No i❑ Water Table=Depth ------------------------------------------------Rock Size ---'-_--_ r i" 9 / �..-- 1 Distance to r1garest: Well ----------------------------------------Foundation -------------------- Prop. Line _....-..-- .......... 16 t . REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------- - --- Date --------------- --= -----------_) 3 -w Septic Tank S ecif Re uirements ' _ Disposal Field {Specify Requirements) -----= --------------------------------------- -----=`'----------------------------------------------------- --------------------------------- i i J f1� � i------------------- ------------------------------ --------------- -------------------------------------------------- (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 Compensati:nilaws of California." Signe T iOwner ------------------------------------------- '� i __ By -----f Title �� ------------------ - -- ---------- -------------------------- --------- other than owner] -' -'-� FOR .DEPARTMth'T USE ONLY APPLICATION ACCEPTED BY ------------ VJ_JF I DATE ----------- BUILDING ------------------------ PERMIT ISSUED .--- ------------------------------' ---�- - ----DATE ADDITIONAL COMMENTS ------------------------------------ _' ------------------------------------------- 3 - . c: ------------------------------'----------------------------------_------------------------------------------------------------------------------------ ------------------------------ - - __ Final Inspection by: - - = �"KV .Date 0 6 - G 1 SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M