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f''"" FOR OFFICE USE: � 14�I APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- Permit No. _ _3__7 c � (Complete in Triplicate) (( L� _�P. ---------------------------------------------------------- This Permit Expires 1 Your From Date Issued Date Issued ----!__13. 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 grid Regulations: ey 5 JOB ADDRESS/LOCAT E' h. �i�r CENSU TRACT --------------•----------- Owner's Name -- ---- - - ---------- --- - --- -------, /--- Phone Address - -------- ---- City // ------------------------------- !5�-,Name l - --_License # --1-t� _� y Phone ------------ ----_---------- Installation will serve: Residence Apartment House,li Commercial ❑Trailer Court ❑ MotI Other -------------------------------------------- Number of living units:_____!__.___ Number of bedrooms _- _____Garbage Grinder ---r=---- Lot Size -------------------------- --------------- Water ________________________------------- Water Supply: Public System and name ---------------------- -----------------=----------------------- •--- =a--cP�riivate,,� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ lay LoaA ❑ 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 availa I within 200 feet,) 7 i PACKAGE TREATMENT [ ] SEPTIC TANKYJ jize�_- _� ....X..___.J� __ ____ Liquid Depth ____ .--- Capacity 416 Typ�/ 1 aterial____� No. mpartments Distance to nearest: Well ___._-___'C1_ __ ___________Foundation ._- --_ Prop. Line l LEACHING LINE [ No. of Lines _________5-_---_-__ Length eeachh line--------,(,LQ__- -_ ____ otal Length .. .......... 'D' Box .--_I----- Type Filter Materia ___camDepth Fil aterial -- /g..........I.. ................... Distance to neyet: Well -___�1�Q_ __-_ Foundation _____ ________ -_-_ Property Line ---s..� SEEPAGE PIT [ Depth ---�5Diameter __ _. Number ------_____ _______ ___ Rock Filled Yes No Water Table Dh -----------------�.Q --- ---- /..i. .. _____._.Rock Size ___ __�..-.. Distance to nearest: Well ._�_ Q__ __ _ ___________________Foundation __._ __ _. __. Prop. Line _.._�.?_ ------- REPAIR/ADDITION(Prev. Sanitation Permit# ___________________ _______________________ Date ----------------------------------) SepticTank (Specify Requirements) ---------------- ---------------------------- -----------------------•---•-------- -----------•-------•--------------- ------------•------- Disposal Field (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 i ormance of the work for which this permit is issued, I shall not employ any person in such manner as to becom subject to orkman's Co ation laws of California." Signed --------- -- ------------------------- - --- --- Owner--- BY - -- - --------- ----- 2 Title - ------ (If other than owner) Z FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY - "--- --- ------------------------------------------------------------------=----------- DATE ----5 '`� 3----__ BUILDING PERMIT ISSUED -=----------------------------------------------------------------------------------------- --------------DATE -- ---- ADDITIONALCOMMENTS ------------------------- --------------------------------------------------- ----------------------------------------------------_----------------------- ---------------------------------- ---------- ----- - ------------------------------------------- ----------------------------------------------- ------------------------- ------------------------ ---- - ----- ------ ----- - --------- ----- ----------- ---------------- ------------------------- ••--•- - ----------------------------------, "- - ----------------------------------------------------------------------------- - Final Inspection by. ----- ------------------------ ------------------------------- --------Date ------- -'+ " t. SAN JOAQUIN LOCAL HEALTH DjSTRICT E. H. 9 1-'68 Rev. 5M