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I FOR-OFFICE USE: y� Y APPLICATION'°FOR SANITATIONPERMIT ------ ------ ------- -------- ----- '` Ate._ _ . Perml�N7�_'-57 ._ ----•----- - ---- -- ---------------------- --------------------------- This Permit Expires 1 Year From Date Issued 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 S �� f f 1'I��,i ---------------CENSUS TRACT ----------------••------• kOwner's Name -- ----/`-<....V{------ ---------------------------- ----------------------- Phone ------------------------------ I r- Address i5-- �� f----�------------------------ City --------------------------------•---------------------------------•-•------- ------------- - S✓,�1� _ _ ,`--.'�:,w .7-7License#� _"'------ Phone ------------------------------ Installation ------------------------- Contractor's Name _._---___ -------- - " - Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ; ] I Motel ❑ Other -------------------------------------------- /] Number of living units:----/------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -_-_-62- �------------•------•- Water Supply: Public System and name ----------- =-------- ------------------------------------------------------------------- --------Private:❑ i Character of soil toga depth of 3 feet: Sand'ji Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ i Hardpan ❑ Adobe '❑ Fill Material --------_y__If yes, type ----------------"'=--' : { l (Plot plan, showing size of lot, location of system in relation too ells, building, etc. must be placed n reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ I SEPTIC TANK'[ I Size------------------------------------------------ Liquid Depth -------------------------- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------• V ` Distance to nearest: Well ------------------------------------Foundafiion -------- -------- Prop. Line ---------------------- r LEACHING LINE [ ] No. of Lines -- ------------------ Length of each line----------------_.---------- Total Length ---------------------------- 'D"Pox------------- Type Filter Material --------------------Depth Filter Material ------------_-------------•---------------- 'Dista.to nearest: Well ------------------------ Foundation ------------------------ Property Lirte ------------------•----- 1C� SEEPAGE PIT ( ] Depth ___.._._---- .. Diameter __----_______- Number -------------------------- Rock Filled; Yes El No .0 Water Table Depth -------=== ^--`' Rock-Size-—- -_-- ----•- i Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop, -Line ------_--------_---- `x REPAIR./ADDITION(Prev. Sanitation Permit# ----------------------------- ---- ------ Date ----------------------------------11 Septic Tank (Specify Requirements) ------------------------------------ ---------------- , Disposal Field (Specify Requirements) ------- - -� -_:i;��-'-"` - ---------------- � `�' 1 .lo ------------------------- _--------'-- -----------_----_---------------_-----= =-- a �. --------- ------------- -- ------ ---------=-------------------------------------------------------------------------------------------- (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 ---------------- ------------------------------------------------------------- ------------------ Owner By --------------------------------------------------- --------------------------------------------------- Title ----- ---- ------------------------------------------------------------ (If other than owner) F9A DEPARTMENT USE ONLY _ 1!L APPLICATION ACCEPTED BY �"`- ------------------------------------------------ DATE - ---- �/ BUILDING PERMIT ISSUED --------------------- --------- _ DATE ------------------------------------------- ADDITIONAL COMMENTS ------ '57"'$� �� ' •---------------- ------------------------ ---------------------------------------------------------------------------------------------------------- -------------------- ---------------------------------------- ---- ----------------------------------------------------------------------------------------------- - ------------- ------------------------ Final Inspection by: __ - Date __ � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M