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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ��//��° Permit No:4W:; 4__. r 1C :mplet oh Triplicate) ----- --- --� .J3_i�,� --�f�� Date Issued --------------------------------------------------.------_ This Permit Expires 1 Year From Date Issued 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 ._ ; T__ ---- -------CENSUS TRACT ---- --------------------- Owner's Name -------- ------- --- ----- --- ------------------.------ Phone yam- Address ---- ------------ 1 �` t ity - - - ---- - -----------------/� � 7 Contractor's Name _.._-_.--. ,� --- -------_ LC ___c ._ ''��,icense # ------------------- Phone '.- Installation will serve: ResidenceX ApartmentHouse,[:] Commercial :❑Trailer Court ;❑ Motel ❑ Other -- ----------------------------------------- �- Number of living units:_____.__. Number pf bedrooms ��-__Garbage Grinder ___`�.___ Lot Size -_ �� -------- ...... Water Supply,Public.System and name ___________________Private �. _--------------------------------- Character of soil to a depth, 3 feet: Sand❑ Silt❑ Gay ❑ ,, Peak❑ , `Sandy Loam ❑ Clay Loam ' Hardpan,❑ Adobe [] Fil! teriafl ------------ If yes, type ------------ --------------- (Plot plan, showing size `of,lot, location of system in relation to eIls,-,buildings, etc. must be placed on reverse side.) p p g p p public �i available within 200 feet,) PACKAGE TREATMENT~ A NEW INSTALLATION: [No SSEPTlC TANK+see a e it permitted if - �r is ava��' - Liquid Depth ____,��_____________ Capacity - L9G�_-___-- Type - Material-_CLNo. Compartments ___ _____:___- °r � � r A Distance to nearest: Well -------------------------------_-1,-_F.,oaundation ____ ______ Prop..Line ___________ .... . LEACHING LINE [ ] No. of Lines -------3-------------- Length of c line______ _ ._ ------__.___ Total Length _- _, ..__..___-_-__ `r /V D' Box ___ ------ Type Filter Material ______ ______ _____ Depth Filter Material -_--_ - ----------------------------- $ 1 - If Foundatione '"Property- Line. - - - -------• Cr ---/-.�__�-_ SEEPAGE PIT [ ] : Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes El No i❑ TableWater l Distance n a • rest: Well ------------------------ ------- --- --Foundat o - Foundation ---------------- -- Prop o . Line ------------------ -- ,�� '► t l REPAIR/ADDITION(Prev. Sanitation_Permit# -----------------------------------`-----��te -------=-----------------------� Septic Tank (Specify Requirements) ------ -�---------------------------------`-------------------------------------------------- - ------------------------------ >> Disposal Field `Specify Requirements) ---------- -- -- - ---•--- ------- -------------------------------------- - ---t---------------------------------- ----------------- ------------ 1 ; ------------------------------------ ---------------- ----------------------------------------------------------------------------------------------------------------------------------- (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 Compensation laws of California." Signed --------- -- ------- ----- _ 1✓ i i `�- Owner- ----------------------- B ---- -- ---- W:1 -B ----- ---- Title ------- ------------- -------------- - - -- - - -- ------------------------------ - i '�ther thanowner) k FOR DEPARTMENT USE ONLY e APPLICATION ACCEPTED BY ----- ------- --------------------------------------------- -------- ----------------- DATE ----- --------- BUILDING PERMIT ISSUED ----------------- ------------ -------- -- --DATE --- - -----•----------------------------- ADDITIONAL COMMENTS -------------------------------------------------------------------------------------------------------------------I-------------------------------------------------------------------------- ---------- ----------------------------`'---- - Final Inspection by: - -------------------------------------------------------------.Date ---------- �---- S JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M