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FUR OFFICE USE:yJ ;��APPLICATION FOR SANITATION PERMIT- Permit No. ___ �'-...... --`----�-) ------ ------ (Complete in Triplicate)---- Date Issued /.-�---�---•- This Permit Expires ] Year From Date Issue ---------- -- ------ ---- -------- q r Application is hereby made to the San Joa u�n,'Local Health District for a permit to construct and 'install the work herein described. This application is made in compliance with Count or No. 549 and existing Rules and Regulations: oZL LOCATIO _______ _____ _____________CENSUS TRACTY6 ----�y--�--••------- ( JOB ADDRESS/ -'--- � � i � t Phone -66F7- ••-- Owner's Name --•------- ------ Address -- ------- -- Address -- �?--- Contractor's Name ------------------ ------- -- �Y License #Cf - Phone I installation will serve:- Residence(Apartment House❑ Commercial❑Trailer Court ;❑ / Motel ❑Other ---- -------------------;------------------ (y �0 ' Lot Size --- G_ 61,`�--------•---- Number of living units:________ Number of bedrooms ---3_-___Garbage r.in er ___ t -----------Private ❑ Water Supply: Public System and name --------------------- = - -------------- of soil to a depth of 3 feet: Sand'El Silt❑ Clay .❑ Pea❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe N� Fill Material ----r--- -;`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 per "n d�if public sewer is a ail liable within 2QQ feet,] ... i uid Depth -------------------------- PACKAGE TREATMENT [ ) SEPTIC TANK'[ ) Size - Capacity -- Lq p fe:. -� I Capacity - --------- ----- Type -------------------- Ma'terlal".- � - -"t• - cNo. Compartments ----------- - each --neetf Prop. Line I Distance to nearest: Well ___.______ _ _ n- - - --- I No.gof Lines Length of Tofial Length ---------------------------- LEACHING LINE [ �*� y -------- - ------ I Depth Filter Mater al ------------------------------------------•- V Box ._t__------- Type Filter Material ------------------- p k _ -o .... j Property Line. ------------------- 16istance to nearest: Wel] ______----------------- Foundation i P Y . y i SEEPAGE PIT [ ) Depth - ------ -- ---- la ------------------------ Diameter ---------------- Number -----------------:--------- Rack Filled Yes [] No ❑ Water' ble Depth -------------- --••---Rock Size -------------------------------- T Foundation --_----------------- Prop. Line --------- ..... Distance t6 nearest: Well ______._.____________________ �,� _rll' Date " ��------ ------ REPAIR/ADDITION(Prev..Sanitation Permit# 1� � - I -N�------- --- ------------------ Septic Tank (Specify Requirements}=--~'-- -------------------------------- =�y----- Disposal Field (Specify Requirements) --- _.______ } --------------------------------------------- Disposal -------------------- ----- - = = jj f, - ' ---- - ---- ---------- I ll - ----- --;-------- �'� , ---------------- 3Yx (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 F County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health bistrict. 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, 1 shall not employ any person in such manner r as to become subject to Workman's Compensation laws of California.” Signed ---------------------------- ------- ---------- -- ---------------------------------- Owner ---- - I ' --- - Title - ------- - ------ --- --------I----------------------------------- By ------- ---- ------- (If ----------- ---------- -------- (If oth an owner") f ARTMENT USE ONLY r F �' APPLICATION ACCEPTED BY ----------- DATE _---�'----- �----------- PERMIT ISSUED -------------- - ----- - --- ---DAT -- --- ----------------------------------- BUILDINGADDITIONQI- COMMENTS --- ------ - --- --- -------------- - - l_ 5 6___________- Fi I rA _ ___ � -- - �------ ------------ ------------- -----------,Date ---- - - Final Inspection b -- -- ---------- --------- ---------------------------------- -- SAN ------- JOAQUIN LOCAL HEALTH DISTRICT 4 ;. E. H. 9 1-'68 Rev. 5M