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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- ------------ ----------- (Complete in Triplicate) Permit No. .V -I v---- ------------------- -------------------- ---------- - Date Issued -__------------------ This Permit Expires ires 1 Year From 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-1 a - - -- --`---�----------��4?� CENSUS TRACT Owner's Name -------- --- ---- �- -------------------------------- -------Phone �_3-D3©5--------- Address ---------- 7�D �^; - ---------- ---------------- City -------------------------•-Q--------------- Contractor's Name --------_C---- '------------------------License #I-�.��I------ Phone 6__1�40•]--- Installation will serve: Residence ❑ Apartment House Commercial :❑Trailer Court ',❑ Motel ❑Other ------ '-------------------- Number of living units------------- Number of bedrooms -----------.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 ❑ 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,) �r PACKAGE TREATMENT [ ] SEPTIC TANK, Size-- ----- .----------- --------- Liquid Depth --- --..--------- CapacityV4CVG�1 Type __&-_G F___-- Material-_CT .No. Compartments __ .......... Distance to nearest: Well ------ ` _-------Foundation ----- Prop. Line -_- -I`.....----- .L - Len .............. LEACHING LINE [ ] No. of Lines --_ Length of each line----______ ---_--_____ Total Length ,_ _-.- �Q ►lwrt� D' Sox .--_ Type Filter Material _ --_-Depth Filter Material --/$- _------------------ ii X $D Distance to nearest: Well -------- Foundation ---f0_1'-------- Property Line S--'t------------- SEEPAGE PIT [ } Depth -------------------- Diameter ---------------- Number --------------------- ------ Rock Filled Yes A No C 6')( .b ,-/ /o Water Table Depth ------------------------------------------------Rock Size ------------------------'------ 17J?I¢IA/ Sid W V0 Distance to nearest: Well .---------/fit?--r --------------Foundation Prop. Line ..... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------_.---------------) SepticTank (Specify Requirements) -------- ------- ------------------------------------------------ -----------------..•--------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------- - ---------------------- ----------- -------- --- --------------------------------------------- -------------------- --------- ----------------------------------------------------------------------------------------------- (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." t Signed -------------------- Owner ` Title -----C y -------------------------------------------------- (I f 24 r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- --- --` - ------------------------------- ---------------------- DATE _- f -�-- BUILDING PERMIT ISSUED ----------------------------- ---- - ----- - -- DATE ------- �; e _ - - - � 1 ADDITIONAL CO ENT '� f��/J - - '-- ..'/�'.- - f=�1c ' -- ��>� e�``-- B_ �-�---------- �� --`�- ------------------------------- ------------------------------------------------------------ -------------- --- - -- - - - - -- ---------------------------------------------------------- ------------------------------------------------------------ --------------------------------------------------- FinalInspection by- ----------------------------------------------- ------------------------------------ ------------ --------Date -------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M