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FOR of icE U',!v APPLICATION FOR SANITATION PERMIT' Permit ( ,o in Triplicate) .............................................. ..... ..................... This Permit Expires 1 Year From Dow 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: Z q JOB ADDRESS/LOCATION ....I�l��l----./�..�..... .. ..................................................................CENSUS TRACT ............. Owner's-Name ....... � i. ......did ..............I............. .. ........ ........Phone .?-31._.h?,5 k....... Address ...........:....... „-�� ..:... .. C'+r ...............City .. }�/�. �-�. . .... ._.__......... � �4... .. . Contractor's Name .............: '.. 1.�'�J..._.... Licensez....7. .............. Phone .` �..........._.. . . Installation will serve: Residence(LApartment House Commercial❑'frailer Court Motel❑Other - . Number of living units..-.-- Number of bedrooms ....3-...Garbage Grinder :........... Lot Size .........--rte. �-�......•.... Water Supply: Public System and name ....:.......................................-•..............................................................Private Character of soil to a depth of 3 feet: Sand n Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam j Hardpan[] Adobe Fill Material ............If yes,type ............... ............ EPlat plan, showing size of to location of system in relation to wells, buildings, etc. must be placed on reverse side-1 NEW INSTA"TiON: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size..................... ........................ Liquid Depth Capacity --------•--.....•--. Type .-_---- Material...................... No. Compartments ......................0) Distance.to nearest: Well -_................................Foundation .......__.._.......... Prop. Line ........_............. LEACHING LINE [ ] No. of Lines ................. ....... Length of each line----....................... Total Length ............................ S y. 'D' Box .:.......... Type Filter Material ....................Depth Filter Material ..... ...................................... Distance to nearest: Well ........."" _--__------ Foundation ........................ Property Line ........................ SEEPAGE PIT [ Depth -------------------- Diameter .......... Number ..... ...................... Rock filled Yes [] No 011 Water Table Depth -------------------......-......................Rock Size ................................ . Distance to nearest: Well ..........:.................+.........Foundation ................._._ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit#` -_____ Date I .. Septic Tank {Specify Requirements} ...................-..................'--- ...... •........................................................................................ Disposal Field (Specify Requirements) ..... r ---------------.----------............•-•---...--. ---------•----------- �. ��--•--- ..............---------......................... ......... ............------------------------------- -------- ........ -------------..................................................................................... IDrow 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 llcen- sed agents signature certifies the fallowing: "I certify that.in the performance of the work for which this permit is issued, 1 shall not employ any person-in-such manner as to become subject to Workman's Compensation laws of California." Signed ---------- --=---------- --...------------•-•••-•............. Owner e V.- 3 title :. By G% --------------••--------•--...-.......- (if of r than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...._ .- _. -----------------------------------•- ...--•-•-----------•-----------------. DATE ... - .... ..- - --- •-� � •----------.: BUILDINGPERMIT ISSUED --•------------- r ------ ........................................-•-•-•-•---......-••-••.---.....--- -------DATE --.-.---------- ADDITIONAL COMMENTS ................... ........................ . ... --------------- -.-. -----.-......-.-:............•.............. ------------------------•------- ------------------------------------------------------------ ................ -•-------..-.•.....--------..--............................................................ --------------------------------------------- --- •-------------------- -� .......--.....- -------•--- • ....------ -.......Date final Inspection by: .. ....... . El / ..- 13 24 1-68 Rev. SM 5AN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M