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FQR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------?'----------------------- (Complete in Triplicate) Permit No. ----- ------ --------------- This.Permit Expires 1 Year From Date 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 with County Ordinance No. 549 and existing Rules and Regulations: d JOB ADDRESS/LOCATION ---- ! ---- ---------------------- ------------------- CENSUS TRACT Owner's Name _.. -�� - ---------- ----- --- -Phone Address ---1� 7-----W----W- /-- - / w - - = t - City -f �� -------------------------------- �^ 4 - Contractor's Name ----4 �'.-{l°�,---- i` ,�/`- ------------------ -------License # yf _ - Phone _ g _ Installation will serve: Residence [Apartment House,❑ Commercial: Trailer Court 0 Motel ❑ Other ----hh------------------------------------- Number of living units:---- ----- Number of bedrooms _-G _Garbage Grinder ------------ Lot Size --/;7 ' - ---------------- Water Supply: Public System and name ----------------------------------- ------------------------------------------------------- Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay-[] Peat❑ SandyLoom ❑ 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 [ ] Size___________________Ja --.__ -- Liquid Depth .---------..___.-. -..__-; � M Capacity ----- Type ------------------- Material- ---- ------- No. Compartments _.------------__...._. Distance to nearest: Well ------------------- ----------------Ft' n ----------------__---- Prop. Line .-..--..__...:........ .. f LEACHING LINE [ ] No. of Lines ________________________ Length o each line_ _ ________._____ Total Length ,__________-________________ � 'D' Box ________-__ Type Filter Material _ __________________Dilter Material _.__________________-__-_•------_-.____-. -n Distance to nearest: Well _________________ ___ Foundati -------------------- Property Line SEEPAGE PIT [ ) Depth ____________________ Diameter ________ _______ Number __________________ Rock Filled Yes ❑ No Water Table Depth ------- Rze -Distance to nearest: Well _______________ ' .--Ftion _________________ Prop. Line _________.________ .__-rREPAIR/ADDITION(Prey. Sanitation Permit�# ___-___-.---- --- --c __________________ Da _____________-__-___-_____-_) � Septic Tank (Specify Requirements) -------- ---- I' s — Disposal Field (Specify Requirements) ----!' _ C _------- C -f1------- ----- f_e ''f, -------- st'---/_T>----------------- ;r s , • -_ - =------------------------------7---------------/-- -- (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 Workm n's Compensation laws of California." Signed ------------ -- ---- Owner By ------- 3..-4! .: ------ Title ---- ------- (If other an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ �C ~ DATE ----------- ------- -7 -� -1 1----------- BUILDING PERMIT ISSUED - ---------------------------- --------------DATE ---------- --------- --------------------- ------------------------------------- -- ADDITIONALCOMMENTS --------------- ---------------------------------------------------------------------------------------------------------------- ------------------------------ ---- -------------------------------------------------------- ---------------------------------------------------------------- ---------------------- --------------------------------------- ------------- - ---------------------------------- ----- - --------- - ---- ---------,- ----------- ------- --- --------- ------ - ----- ---- -- Final Inspection by: ----------- �� -------Date ------------ -' �' --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M _