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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 3-3i..�---- (Complete in Triplicate) 4 --------------- This Permit Expires I Your From Date Issued Date Issued . �r..3.=.-?-3 Application is hereby made to the San Joaquin Local Health District for a permit to construct an +stAl the work hereir described. This application is made in compliance with County Ordinance No. 549 and existing Scald Regulations: JOB ADDRESS/LO TION .__.3_L_ 1 V - ---------- - ------------CENSUS TRACT _---------- _.------ Owner's Name - - - ---- ---, �--------------- - ---------------Phone ----- -- - -------------------- Address --- 7 - -- - ------ -- ----- --- City ----- ---------------- Contractor's Name - -- -- - •--------------License # _�p�3�-7s Phone Installation will serve: Residence Apartment House❑ Commercial oTrailer Court I] Motel ❑Other - -------------------------- Number of living units:------1... Number of bedrooms� -_2"�..Garbage Grinder - ____ Lot Size ----.------------------ ------------.------- Water Supply: Public System and name ----------(dr^l ------------- ------------- --------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑Clay ❑ Peat❑ Sandy Loam {Clay Loam 0 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 ----------- .......... W Distance to nearest: Well ----_..-.._..--------------------Foundation -..-----.-..----_.-- Prop. Line -------.---..--------. 6 LEACHING LINE [ j No. of Lines __ ------ - ---------- Length of each line----------_--_-----.------ Total Length ------------................ 'D' Box ------- Type Filter Material ------.._.......-_Depth Filter Material ................----------.................. Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PIT [ ] Depth Diameter ---------------- Number Rock Filled Yes ❑ No Water Table Depth -------------------------------------------Rock Size ----------------- ------------- Distance to nearest: Well ----------------------------------------Foundation ------.------_----- Prop. Line -----------..-----.--. REPAIR/ADDITION(Prev. Sanitation Permit# ... _- -------------------- Date ----------------------------------) Septic Tank (Specify Requirements) - - ---------------------------------------------------A - 1----------------- -------------.........I---------- ------ - Disposal Field (S/p/gcify Regquirements) -..-r //F�� -_� "iy�, _- I, sJrDe'7-`-- ---- ---�------ ------Z D-'-- - -�0-/--- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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' Compensation laws of California." Signed - - ---------------- - - Owner ---- - - - ----- - - By - -- ----- - - -------- ' --------- V Title ---�tA----------- - (-If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- --- -- ---------- ----------------------- --------- --------------------_ ... DATE --------------- BUILDINGPERMIT ISSUED ----- ------------------ -------------------------------------- -----------------------DATE ------------- ------ ------------------- ADDITIONAL COMMENTS ---- ------------------ --------------------_--------- ------------------------- - - - -- - - -...---- ------- - ------------------------------------------------- ------ ------------------ - --------------------- ------- - - ------- - - - ------------ -- -- ------------------------------------------------------------------------------ - ---------------------- - -- - - - - - - - Finol Inspection by: . ------- - - --------------- ------ ---Date ..... -a.'73------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M