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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. __..7--�- 3 ------ This Permit Expires 1 Year From Date Issued Date Issued ---. 5.7- 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 nOrdinance No. 549 and existing Rules and Regulations: JOB ADDRE55/LOCATI Owner's Name ON . ,J ,� LQ.FI1� - - --CENSUS TRACT .. _� I I��A-f��R�r_ --- - ../}�1- - ------- -. h —/ n ------- ------- -- --------- ------- -Phone - .J'_ �. �Q-- Address - ----- -- /T�.` �_[—c �--_ _ ------- Cit [ !1_jq C 1 v Contractor's Name _ u-� -- - Phone -------------- ----------------- . License #, ---- -- -- --------------- Installation will serve: Residence WR-Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other ----- Number of living units:..__ ----- _ Number of bedrooms ____Garbage Grinder ._ - Lot Size `0, Water Water Supply: Public System and name ---_____-------- ----- - ----------- -------- ------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam J;-- 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[ ] Size------ ----------------- --------- Liquid Depth ...__._ - ------------------- Capacity - ----- -- -- ---- TY Material----_-- --�. No. Compartments Distance to nearest. We ----- --------- Foundati n Prop. Line -..-..__...._,__-_ -- LEACHING LINE [ ] No. of Lines __ _____ ____ ___ Length of each line -- ----- --- -_- __.__.__ Total Length .__-_....._ V} Q' Box -- Type Fi er Material __-----------------Depth Fi edr Material ----.-___-- -------------------------------- Distance to nearest: We I ----------------_.__-- Foundation -__ -._ __.-------_-_-- Property Line _ ---------------------- SEEPAGE PIT [ ] Depth ----- --_- _-- Di meter Numbe- -.____ ---- Rock Filled Yes E] No -- Water Table Depth __.._. ----------------------------Rock Size --.___. ------------------------- Distance to nearest: Founda ' n --------- Prop. Line --------------------- ^ -{ >s REPAIR/ADDITION(Prev. Sanitation Permit# .._. . . --.____ -- - -- --- Date ---- ) - -- - ------------------------- Septic Tank (Specify Requirements) _. --------_- Disposal Field (Specify Requirements) -------L5 .�A R�- lj � - -------- _ f /LV_ ME (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 t e performance of ' t work for which this permit is issued, I shall not employ any person in such manner as to beta su t to ma 's pensatian Paws of California." Signed .. - ----- - ------ -------- -------- ---- Owner By -- -- -- - - - ------ Title - --- ( fother than owner) - -- -- ��'� - ------ ---- -- . - - ----- - -- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY t % �. -� tee_. -------- -------------- -- --- DATE / Z ... BUILDING PERMIT ISSUED ..______-.-___ ___ ___ _ ---- ----- ADDITIONAL COMMENTS --_. ___ ----..DATE _ --------------- -- -- ---- -- -- --------------------------- ------ ------- --------- ina Inspection : �- ----- -- ------ ------Date --- --- --- SAN - `. . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M