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FOR OFFICE USE: APPLICATION FOR SANI'TATI'ON PERMIT (Complete in Triplicate) Permit No. _Z=_-7 p ---- ------- ----------------------------- ------ This Permit Expires T Year From Date Issued Date Issued J,_I,__- 1� 4 Application is hereby made to the S n 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/LOCATION021(l-------- --- _----_CENSUS TRACT Owner's Name -- --- -•- Phone Address - � -_ -/�--'-- l Ci Contractor's Name ------ 1- -_ --------- L'icense ------ # _l' 3 ?� Phone Installation wilt serve: -_ Residence 0 Apartment House❑ Commer 'al :❑Trailer Court ;❑ Motel ❑ Other _--- .......... Number of living units:__ Number of bedrooms _______Garbage Gri derma_-_.____-__- Lot Size ______---------__-_- -----------•----- ! Water Supply: Public System and name ------------------ �Q<< --------I--- ----- ----------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'* Silt❑ Clay [:1 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,) PACKAGE TREATMENT ( SEPTIC TANK f I Size---------------•--------------------------_----- Liquid Depth ---------------_-------- - Capacity - -------------- Type -------------------- Material _____ No. Compartments ---------------------- Distance to nearest: Well -------------------------- -----.----Foundation ---------------------- Prop. Line ---------------------- + LEACHING LINE [ 1 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 - GY Requirements) ments) --------�- --, ----�---'--`--------�----�----c.1e t✓ - --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 r as to become subject to Workman' ompensation laws of California." Signed --------- --------------------- .....- --- �-- --- ------- Owner ---- - -- --- (- By ------ - ---------------------- ----- J`��'-,Title -a = � � (if ot er than owned --- --- FOR DEPARTMENT USE ONLY x APPLICATION ACCEPTED BY ------'- '----------------------------------------------------- -- ------------ __ -- . DATE ------ -oz -7�-, BUILDING PERMIT ISSUED --------------=I------------- - - DATE . ADDITIONAL COMMENTS _________________________ - - ---------------------------- --- ---- --------------- ---------------- - ----------- -- ---------------------------------------------------------------------------------------- ----- ----------- --------------------------------------- ------------ - _ Final Inspection by: ..l ------ --- ------------------- ------------.Date ---- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 7-'68 Rev. 5M