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FOR OFFICE USE: R APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No -------- ---------------------"--------"---------------- This Permit Expires I Year From bate 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 wit County Ordinance No. 549 and existing Rules and Regulations: ? JOB ADDRESS/LOCATIONIRZ r _ - Q-__- - --- CENSUS TRACT Owner's Name .-- _ -- -- -�1Z.cCJ_ --------------------------------------------- Phone Address --- -{- -, --- -----�-�f----•- Cit Y " ------------- Contractor's Name __ _ License # _la° Phone Installation will serve: Residence Apartment House❑ Commercial ;❑Trailer Court Motel ❑Other-------------------------------------------- Number ------------------------------- -- - Number of living units_____________ Number of bedrooms _3___--Garbage Grinder ------------ Lot Size ___ - - a--- ' -- ater Supply: Public System and name ------------- ------------------ ------ -------------------------- ------•---- ------ - . Private � y Character of soil to a depth of 3 feet: Sand❑ ,- - Silt 0 Clay ❑ Peat❑ Sandy Loam 4 Clay Loam � �} Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type ----------------------- - (Plot plan, showing size of lot, location of system in relation to wells, building's, etc, must be placed on reverse side.) NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) �► PACKAGE TREATMENT f ] SEPTIC Size TANK ` --------------------------------- Liquid Depth [ ) --- ----------- -------------- ------- Uj 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 [ ] Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No .0 Water Table Depth ------------------------------------------------Rock Size f Distance to nearest: Well -----------------------------------------Foundation'--__-__----_------- Prop. Line ............... • ---REPi AIR. ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -----------------------__--- } f Septic Tank (Specify Requirements) { Disposal F' Id (Specif i Requireme ts) ____-_ _-14_---. Q-- -------- --- ---------- ......... --------------------------- ----------------------------- -------------------- ----------- ----- --------------------------------------------- ---------------------- ----------------------------i--- "---------------=-------- --- ----- -----------------------:_.__------------------------------------------- - (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that '.the workwill�be_Aone-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 ------- ------------------------------ of other than owner)". • � • FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_- -------------------- BUILDING PERMIT ISSUED -------------------------------------------------------------------- DATE ------ — ��' ADDITIONAL COMMENTS ---- ----- ---------------- - ----- - ----------------------------------- ---------- - -------DATE ---------------••------- -- -------- - -- - ------- --- - ----- --------------------------------------- ----------------------------------- ------------------------------- - - ------------------------------------- --------- ---�---- - -^ina Inspection by: --� - -- ~- ------------- ------- - ------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM