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FOR 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: JOB ADDRESS/LOCATI N __5.5?3 ______.._____CENSUS TRACT _--_____--._.._______ Owner's Name - ----.. -----------------------------------------------------Phone -------------- -----•-•-----. ----- Address 5,5 ' -- --- ------------- - city � ' --------------------------- r ---- --- Contractor's Name ---- _ ------.License #11Z3-k Phone ------------------------------ Installation will serve: Residence P�Apartment House❑ Commercial :❑Trailer Court i❑ Motel ❑Other Number of living units:---- Number of bedrooms __,2'`__Garbage Grinder ------------ Lot Size --------- --- ----------- _-'=_--------- Water Supply: Public System and name ------------------------------------------------------------------------------------- Private . Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E] 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.) UI NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) LV PACKAGE TREATMENT f ] SEPTIC TANK,[ ] Size-----------------------------------.------------ Liquid Depth .-.__________________ __ 0 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 ------------------------------I............. 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) -------------------------------------•-------------------------- ------------------«---------------------------- Disp sal Field (Specify Requirements) Q-x - (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 gned ----------------------- - --- -------------------------- - - -------------------------- Owner �" _Y 2=L�_e-c� - / �- ---------- Title ---- I----i----------a - ------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -' ------ ----------------------------------------------------------------. DATE ':/ _' ----------- BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------- ----------------------------- ADDITIONALCOMMENTS - ----------------------------------------------------------------------------------=--------------- ----------- -------------------- ------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------- - - -------- -- ------ Final Inspection b -' ---------------------------------- --- ---- ----•- - ------ ---- ---- --- PY� ---------- - ---- - -- --�?,ay - ------------------------------------------------------------------------...Date -��----��-�- -/-I--- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M