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r:'-FOR OFFICE USE: ` APPLICATION FOR SANITATION PERMIT ' p pi (Complete in Tri lcate) Permit No. 1- , ---------------------------------- - This Permit Expires I Year From Date Issued Date Issued v- " 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: r JOB ADDRESS/LOCATIONSO_ IPQ_ _-_____ " -------�------j---4-CENSUS TRACT `Owner's Name 4 I _iPhone Address - ---- + - `AL1 , Contractor's Name _ �- �'��•�,/ � - - -------- ---------------------License --- ---- ` ---------------------------License # ; - __ Phone _Gt_/5-G3.4 - Installation will serve: Residence 'Apartment House Commercial❑Trailer Court ;❑ Motel ❑Other --------------------- Number of living units_____________ Number of bedrooms __.3___-_Garbage Grinder ------------ Lot Size Water Supply: Public System and name __ --------------- _..� -----------------------------------------•- Character of soil to a depth of 3 feet: Sand l Silt. - Clay Private �. ❑ y ❑ - Peat�A Sandy loam -1 �C06y Loa m Hardpan ❑ Adobe❑ Fill Material XV---- If yes, type -------------------- ---- (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) N NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] `11 PACKAGE TREATMENT [ ] SEPTIC TANK' X.jD_ X"S_ ,� [ ] Size -_ ____ Liquid Depth _-"" Capacity___.____[}"" Type PA ----------------------- Material [`` No. Compartments i� Distance to nearest: Well ___b ," ........ • 'i - -- ---------- •----Foundation _l_0------------- Prop. Line --------- ------------ LEACHING LINE [ ] No. of Lines ___-Z--------------- Length of each line_____75_ ` - --------- Total Length __ _�S - --------------- D' Box ___/____-_ Type Filter Material /�_. ___" p .Depth Filter Material ---- Distance to nearest: Well ____6~®_ -_"_"-_ Foundation ----/__6 ` __ ______ Property Line, _�___.__ SEEPAGE PIT ------------ .�� [ l Depth -------------- ----- Diameter ---------------- Number -± ------- -- --____-___ Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------------------------ -----Rock Size --------------------•- Distance to nearest: Well ----------------------" _ _ - -----Foundation ----------------.--- Prop. Line ---------------- ___ REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ------•--------------- ] Septic Tank (Specify Requirements) ------------------ -- ----------------- ------------------- Disposal Field (Specify Requirements) ------------ ------------------------------- -------------- - _ -_.._�-- _-� .� ----- - ----- - - ------- ------------------------------------------------------------- -- --------------- (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 Work 's Compensation laws of California." Signed4� r >- ____ Owner Y ------ ��- ------------- Title --------------------- ------- - (If other t an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------7-. . BUILDING PERMIT ISSUED ----R------ ---------------------------------------------------------------. DATE ADDITIONAL COMMENTS = DATE - --- --------------------------------------------------------------- --------------------------•- --------------------------------------------------------------- -------- ---------------- --------------------------------------------- - ---------------- ---- --- - -- --------------------------------- -- --- - ------------------------------------------------------------------------------- -_ Final inspect' _ --------------------------------------------.---.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M