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4 � { FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {' --------------------------1----------------------------- Permit;No. �I1 t (Complete in Triplicate) i 11 J This Permit Expires 1 Year From Date Issued Da#e Issued _.__ _'Z_Z_7 ------------------------- -------------- ------- --- - sApplication 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 wou y O di ante No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N� . - -T---------------- _CENSUS TRACT ------� �'----------- Owner's Name.. ---- J --- -- ------------ c� Address f� — �� -- ------------- -- ---------- ----J_-Ju-- ----; . City Phone L`3 - I Contractor's Name I� J -- ------ �''"`` ' " ` .License # � _ _ Phone i Installation will serve. Residence ❑ Apartment Hous 0 Commercial :❑Trailer Court C] I Motel ❑ Other --- -------r ---------- � .�h�t�r---^-a --------- Private of living units:-...-/'-- __ Number of bedrooms -___- -----Garbage' Grinder _________._ Lot Size ________ Water Supply: Public System and name -- ------------ Peat Sand Loam ,E] Clay, -- Private —� Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ ❑ y ❑ y am ;❑ Hardpan ❑ +: Adobe'❑ Fill Material ------------ If yes, type --------------- --------- (Plot --____(Plot plan, showing size i�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,) qd PACKAGE TREATMENT [i�] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -______________.--.----• Capacity -----------------`- Type -------------------- Material--- --- . - ---------- No. Compartments -----------------_- Well ----------------------- ----- -----Foundation ---------------------- Prop. Line -------Distance to nearest: ------:----•--- LEACHING LINE [ ] No. of Lines --------------- -------- Lengthofeach line---------------------------- Total Length'___________.--------_-_-- D ______-_- _.__D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------------------------- Distance ________ ;'__ __________________________Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line SEEPAGE PIT [ ] Depth --- ----- Diameter ________________ Number --------- ------------------ Rock Filled Yes [] No l❑ if. Water Table Depth -------------------------------------------------Rock Size -------------------------------- .� i _ ,i Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ----------_-_------ �I REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date -------- ------------------------- I Septic Tank (Specify Requirements) ---------- ------ --------------------------------------------------------- -------------------------- T Requirments) ------------- ----------- Disposal Field (Specify iis - -- -------------------- ------------------------------------------------------------------------------- III --------I----------------------------- r' I (Draw existing and required addition on reverse side)I hereby certify that I hae prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, StateM 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 Com ensation laws of California." d Signed -- - --- -------------------I�----------------- ------- ----------------- -- ------ OW BY ---- ----- - ------------------------------- •- --- ----- Title: r (If other th"n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTi±D:I BY ----------------------------- -- ---------- DATE _ .. �' 6 7 ---- --------------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ --------------DATE ------- ----------------------------------- ADDITIONALCOMMENTS -----------------------------------------------------------------------------------------------------------------------------------=--------------------------- ,il ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ----------------------------------------- ------- -----------------------------------------��----------- ------------------------------------------------------------------------------------------------------------- -------- •------- ---- ----- --------------------------------------- ----------I-------- ----------=-------------------------------------------------------------------------- h Final Inspection by: --------------- --------------------------Date --- '------------ SAN -- --- j SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.