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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- ' Permit No: . 20 (Complete in Triplicate] -------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -s 3a�-, Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal! the work herein described. This application is m�ncce with C un y Ordnance No. 549 and existing Rulp s Regulations: Iva JOB ADDRESS/LOCATION -- - --------CENSUS TRACT -------------------------- Owner's Name --------f 1-�----t"` ------?r� -------- --- •--------- ---- ---Phone Addressc� �� W - 1 --------------------------------- Cit ---••--------... Contractor's Name ---_ ------------------------------------ - V Phonee # - � __ --- _ __ _ Installation will serve: Residence Apartment House-E-] Commercial ❑Trailer Court k❑ q Motel ❑Other Number of living units-------/__ Number of bedrooms _�A7-__-Garbage Grinder ------------- Lot Size _---------------_--_--_- Water Supply: Public System and name ------------------------------------ -------------------- -------------------------Private (� Character of soil to a depth of 3 feet: Sand'R3 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam E] r 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 I Size---- - --------- Liquid Depth --- --------- C opacity /'rMO------ Type - Material. + No. Compartments Distance to nearest: Well --- -- --------------------Foundation ---L--- ------------- Prop. Line _43----------------- .� r C LEACHING LINE [ ] No. of Lines ------------------------ Length of each line,--' _ P------ Total Length D' Box -__f------ Type Filter Material - _ _ _-_Depth Filter Material -1 ''r - X-c p................. 1 Distance to nearest: Well --__-s`��___--_ Foundation ----I--! ------------- y L _---_____ Propertine S?.._---- -----•--- SEEPAGE PIT [ ] *Depth -------------------- Diam -- -------. Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------- ---------------------Rock Size ---------------------- - Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------........ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic --_-_--_-- _-.---_-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 he 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." I Signed --- --- - -- ------------------ Owner ------------- - BY ------ -�-- ---------- Title --------- ------ --------- --------------------- ------------ ------------------------------------------- I other than owner) FOR DEPARTMENT USE ONLY n APPLICATION ACCEPTED BY ---------------------------------- DATE -----` r � �r - -- ---- -------------------------------------- BUILDING PERMIT ISSUED ----- ADDITIONAL COMMENTS -------------- - - --------------------------------------DATE ---------- ---------------------------- --------------- ----------------=-'-----------------------------------------------------------------„-_-_-____--__--___------____�---__--_-_^--_�----`_5---.�--_�--�_-------�-_----_----.-----._ -- t Final Inspection bY- ------------- ------------------------------- -- -.Date ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M t��