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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - //7/,We--------- < 41------- Permit No. _ l [� (Complete in Triplicate) - 1 (� ` �} `� 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/LOCATION ._______ �_ ________ ._ _ �______ __.___._______CENSUS TRACT -----------............... OwnersName _---------------�-- --------- --------- ----- Phone. ~- .............. Address -------------------------------- -------- ( City -------------------------------------•-- P Contractor's Name ______________ ----- 1�7---------------License# -------.------____---- Phone �? `lGa.7... Installation will serve: Residence y Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other -------------------------------------------- //' Number of living units:__-J-_ Number of bedrooms __�';.....Garbage Grinder ________ Lot Size ------!_ed__ ----l-5-0....... Water Supply: Public System and name ---------------------------------•-----------------------------------._---.------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] 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 ----------- ................ 'v 'D' Box ____ ------- Type Filter Material ______________-____Depth Filter;Material -------------------- ....................... Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line __..___-.__-___--._.--_ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -----_..------------------- Rock Filled Yes ❑ No C] Water Table Depth ------------------------------------------------Rock Size ---- --------------- ........... Distance to nearest: Well _____________________________________Foundation -------------------- Prop. Line -.--___--_.___..-•---. REPAIR/ADDI.TION(Prev. Sanitation Permit# -------------------------------------------- Date ..-_______-._-.-•--___-_____---•-) Septic Tank (Specify Requirements) -------------------=------------------------------------------------ ----------------------•-----------------«-----------------------•--- Disposal Field (SEecify Requirements)' --- - -----------`�------- / --- --------------- - ---------- C1 --- 3 --- Yjrcz .�, ---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------•-- ` (Draw existing and required addition on reverse side) I hereby certify that I have pr4ared 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 whkh'this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." r Signed ---------------------------- ------ Owner- --�rBY - ------ ------------------------ Title othe t n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 'IV - --------------------------------------------------------- DATE � 7�6� BUILDING PERMIT ISSUED ------ { ---=--------------DATE ------------------------------------------ ----------------------------------------------- ----------------------- ADDITIONAL COMMENTS ____________________________________________ ------- ---- - ------------------------------------------------------------------------ �1 W --------------------------------------------------------------------------- ---------------------------------------------------------------------- --------- ---------------------------------------- �fl� ---- Final Inspection by: , "� -------------------------------------------------------------Date --�!/t SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M