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FOR OFFICE USE: \UAPPLICATION FOR SANITATION PERMIT Permit No. -------- ------------------------------------------------ � �Cd.r-_,�v�-� (Complete in Triplicate) ---------=------------------------------------------------ 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 compliancewith County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._/_ ____ : Gf� �'------ _______,__._ CENSUS TRACT ___-s= _/.___ Owner's Name ,,// :!/� - ----------- --------------- ------- Phone Address -------------7 �� - - ------��---�//------- *. City ---6.� - ---- ------ - --- Contractor's Name - _ _ __________ _ _ -_1G1°_ License #o' d_ °. ..1 Phone : ' /eta'" Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court 0 Motel ❑Other-------------------------------------------- Number of living units:------------ Number of bedrooms ._.-----Garbage Grinder ---d------ Lot Size ----- c?____A .- ...... Water Supply: Public System and name -----------------------------------------------------•------------------•- ----------------------------------Private❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam X 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[ J Size_---------------------------------------------- Liquid Depth ---------------- t� Capacity ------------------- Type -------------------- Material---------------------- No. Compartments Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line _____-___.. .......... LEACHING LINE [ ] 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❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line __________---_________ REPAIR/ADDITION(Prev. Sanitation Permit#/_______--_:_________________________________ Date ---------------------------------- Septic __-_-____--_-__-_- ____-_____Septic Tank (Specify Requirements) --- 1a ----- +-------------- ------------- Disposal -----------Disposal Field (Specif Requirement --------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- --- - -- - --- --- --------- (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." Signed .-- ----------- By - - - -------------- Owner BY ----------------------- Title ----- y y, --- (If other own --------------------------------------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1----------------------------------------------------------------- -----. DATE --- -L( BUILDINGPERMIT ISSUED -------------------------------------------- -------------------------------------------------------DATE ---- ------------------- ---------- ADDITIONAL COMMENTS ---- ---- ----------------- - - - - -----------------------------------------------------------------------------------------------I------------------------------------------------------------------------------------------ ------------------- -------------------------- - -- - - - ------------------ f ' Final Inspection by: --------- - ------- ------------------------------ •--------------------------------------Date -6-`�j- ----`- ----- ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M