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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------------------- (Complete in Triplicate) Permit No. --------------------------------------- ------------------ This Permit Expires 1 Year From Date Issued Date Issued -_---_Q-7q "",) . 0� 9-zYo^3s Application is a eby ade t the J i I Health Jj}is ri or r t o uct and install the work herein described. T i p6�ma i c lance with Co di ce a a ekisting Rules and Regulations: r aA DR S ATI I� � a. . �f�/9y_� V(A' - --------CENSUS TRACT -------------------------- Owner's Name r. Phone,_- Address ------ - ------ -----•------ -l�--� 'Q+- - ---- - --- --- ------------ City - -- - -Contractor's Name ._____- .._ - = x_---__.License #-_l O. y Phone ______--------------I......... Installation will serve: Reside ce Apartment House❑ Commerci �iler Court ;❑ Motel ❑Other -------------------------------------------- Number ___ ________________________Number of living units_____________ Number of bedrooms 'r__Garbage Grinder Lot Size ----_____________._____________--________ Water Supply: Public System and name ------------------- - _ -------------------------------------------•--.------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •Clay Loam .[] `1 Hardpan ❑ Adobe-❑ Fill Material ----------_- If yes,type ---------------------------- ap ^0 (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,) i PACKAGE TREATMENT { ] SEPTIC TANK'f ] - '', r Size----------------------------------------- ------ Liquid Depth .--------------------.-_- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------------------_- Distance to nearest: Well ____________________________________Foundation ----- ---------------- Prop. Line ------- .............. LEACHING LINT: ( ] 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 I❑ Water Table Depth --'---------------------------------------------Rock Size --------------------------- -- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-_-__-.-----______________) Septic Tank (Specify Requirements) ---------------- - ,- Disposal Field (Specify Requirements) _ ____ Q �� -` �"-------- `-------- � - - - - - - ------------- ------ raw 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: "1 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 W n's Compensa ' laws of California." Signed ----------- --- ---------- -------- -------- Owner ,Q By ----------------------------------- f. ---------- Title` rI_tt'[_2-----r- '__11'---------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY 00, APPLICATION ACCEPTED BY _-- _ --------------------- DATE -- ----"' I-'_-7 -------------- - -------------------- ----------------------------------------- BUILDING PERMIT ISSUED ---- --------------------- - ------------------------------------- --- -- ----------------------- -------DATE ------------------------------------------- -- ADDITIONALCOMMENTS --------- --------------------------------------------------------------------------------------------------------------=------.---.---------------- ------------------------------------------------------------------------- Final Inspection by; ---------------------------------Date - --- � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M