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FOR OFFICE USE: APPLICATION FOR SANITATION PER�'�',gNN �II (Complete in Triplicate) P&—,m No. .��"y'. _7 -- -- - ---7- -- ----- E P ' - - -- -- """--- -- This Permit Expires 7 Year From Date Id - -"-"--" issued-- Date Issued -. - I?_e-0; Application is hereby made to the San Joaquin Local Health District for a described. This application is made in comp6tance with County Ordinance No. 549 and xisting Rules and Regulations: Permit to construct and install the work herein JOB ADDRESS/LOCATION _/. S"=a ------ /?-T/ Owner's Name _.l6yar - - --- --CENSUS TRACT ------ Owner's p /� vl .------------_-------------- -------- - - - Phone Address - �'f r�Q 1. 7j• - ---- --- - "__ -��---------------------. City Contractor's Name - - --------------------------- - -----..License # --------------- --- - Phone Installation will serve: Residence4l Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -- - -- -------------------- -------------- Number of living units:_-_-- .--- Number of bedrooms ---- -----Garbage Grinder Lot Size .."_- Water Supply: Public System and name ._." "_- -- -- ----- -- ------ Private] Character of soil to a depth of 3 feet: Sand❑ Silt Cla ❑ y ❑ Peat❑ Sandy Loam k Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material _.__""__ If yes, type ---_--- _-_--_-------_ blot 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 7 Size---------- --------------__._--__-_--_ Liquid Depth -------------_.--------- Capacity --------------- TYpe ------------------- Material------------------- No. Compartments ------------------- Distance to nearest: Well ----------- -------------------.----Foundation -------.--------.----- Prop. Line ----------------- _._ LEACHING LINE [ ] No. of Lines ----- ------------- Length of each line --- _ -----_. ---------- Total Length ------- -------------- ----- N 'D' Box ------ Type Filter Material __._.".._____._.Depth Filter Material ----------------_...___...____.__........ Distance to nearest: Well ----- ---.-------------- Foundation .._""___--------------- Property Line _ SEEPAGE PIT [ ] Depth Diameter ----------- ---- Number --------_------------ ----- Rock Filled Yes ❑ No ❑ Water Table Depth --------------- ------------Rock Size ----------`------------------- Distance to nearest: Well ------------ ----------------.........-Foundation -------------------- Prop. Line ---------- REPAIR/ADDITION(Prev. Sanitation Permit# _.._"..---- .___._.___ Date _-."._. ----------------------- Septic Tank (Specify Requirements) - --- ------------------- -------------------------------- -------------------------------------- ------------------------- Y Disposal Field (Specify Requirements) --------------------- --- -ate ---------------------------------------------------------------------------------------------- ----------------------------------------------------------------- (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: "1 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 sqbject t Wok an' cC�ompensation laws of California." Signed .--- - 4-- ----------------------------------------._._ Owner By - - --------- ------------ ---- --- - - - ' - Title -- ..... .. (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - •------ -- ---------- ---------------- -- - -------------- DATE J: ... BUILDING PERMIT ISSUED ------------------------------------------------------------------------------ - ----...----------DATE ------------------- ADDITIONALCOMMENTS - - - ----------------------------------------'----------------------------------------------- ------ -------.._._ -- --------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- -- --------- ---- --------- - ---------------------------------------------------- ------------------------------ ------------------------ ------------------ --------------- --------------------- ----------- --- ---- - ------- - _ _ _ -------------------------_ ------- r �} ----- Final Inspection by: - e - Date- ---- -` --- - -- - ---- ---------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M