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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _3�/ ............. .....................-. Permit No. ...? ............ - (Complete in Triplicate) ...................... 'Chis Permit Expires 1 Year From Data Issued Dote Issued .._s! 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 C u ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ,.rx�..1+�....�.��.. � •............... ... .,��--.. ..._. ............-......CENSUS TRACT .......................... Owner's Name ........ . .,_.. G��'4�............. ... Phone .................................... Address .......... .�. !, . __ .....C_..y.... �?..'�`1 : .... ....... City �....... ...................................................... .. , f Contractor's Name t --...----.License # Phone ........................... Installation will serve: Residence ElApartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other ...........-------.......-------------...... Number of livingunits:._ _______-- Number of bedrooms . .. Garbage Grinder _...----__-. Lot Size -------------------------s. A"Z. -__--• Water Supply: Public System and name -------•_...•.. ------- -•-•---•----------------------•-----•--••---- .........................................Private Character of soil to a depth of 3 feet: Sand❑ t❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam ❑ Hardpan Adobe ❑ Fill Material ------------ If yes,type .......................... IJV (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.[ q�) y NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet.[ PACKAGE TREATMENT [ ] SEPTIC TANK i ] Size-_•....................................... ... Liquid Depth .......................... Capacity ....... Type -------------------- Material------...........--... No. Compartments ...................... . Distance to nearest: Well ....................................Foundation ....... Prop. Line LEACHING LINE [ ] 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 [ j Depth Diameter -- -..... Plumber -------------_------------- 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) ------------_----------.............•---••----------...... -----... ........ ----•--------•-•------ ..........-ft+ Disposal Field (Specify Requirements) .... ._ .... !- --r-� _.........._. -................ _.._.. _ .--••............... ..••- ----- ......... - IDrow 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's Compensation laws of California." Signed ------------------------•---...... {._. �""7..... ............._.__. Owned - --- 00 BY ..... .................................... ........... .:. ..�- �� - .... Title .............. (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -• • . .....---- ........................-•............................... DATE .07.7.7_7 Z --- ....... BUILDINGPERMIT ISSUED .................... .......... ------. --------------------.......-.-----....._...........:......------..DATE .........................._ ............... ADDITIONALCOMMENTS ......................................................_..--.............._..........................-.............................:........................... ......................................................... ----------------- _ _ ------------------ ---- ----.-- -.-----.---.-------------- Final inspection by: ------ ....................................................................DateL) --..-- ' ------ SAN JOAQUIN LOCAL HEALTH DISTRICT yyw E. H. 13 241•'68 Rev. 5M _ 7172 3 M