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FOR OFFICE USE: APPLICATION FOR 'SANITATION PERMIT ----------------�' Permit No. (Complete in Triplicate) 3 - ------------ ------------ - --------------------------- �� This Permit Expires 1 Year From Date Issued�-------- Date Issued __1,11112J -----------------____ -_____-.------_. 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 C untyOr inance No. 549 and existing Rules and Regulations. 4 JOB ADDRESS/LOCATI N ` _-'-- C�`ENSUS TRACT __._.____________________ Owner's Name s r ----- ------Phone QGG��G� Address /-1'---1" r �_. C .e Yf' city✓" L'j ---------------------------------------------- 's -- -------- ----- _ Contractor's Name _-___ _-- -_-' _ �!� __._.___-- _..._._--.License #rj � ✓� Phone . Installation will serve: Residence�<Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ---------------------------- --------------- Number of living units:---/---- Number of bedrooms-__-_Garbage Grinder _1` _S Lot Size __-___--_---._________________._-__-_.- WaterSupply: Public System and name ------ .. P_-------------------------------------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 _-_-_____.-________________ , c (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] ;ze X----.��--------------------- Liquid Depth _- �,------------------ Capacity�/ ,__ Typ __ . ____.__- Materialef�' t.___ No. Compartments ________.............. Distance to nearest: Wel '"-_ "___________________Foundation _ ----------- Prop. Line ...... LEACHING LINE �+Q No. of Lines ---�-. , _______________ Length of each linne�e-__ ----------------- Total Length ,,o... _. -----_--___-_--- D' Box ._ '__ Type Filter Materepth Filter Materia/l00,;1,,V---------------- Distance to nearest: Well _. ------------ Foundation _,f�_____________ Property Line _./ --.--_.._..__ —e E SEEPAGE PIT 2 Depth _#� _-P-.-.-___. Diameter ---- Number ---,�'_-__ ---__._.___.__ Rock Filled Yes No 0 Water Table Depth _____ 10 01*-----------------------------Rock Size_-_ -___-__------- S —f Distance to nearest: Well ..--:."-.- __________________Foundation _1V1 __-_----._.- Prop. Line _-��.-.---. ......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ___..-__--.._.-_---__-___----_____) Septic Tank (Specify Requirements) ------------------- ---------------------f---------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------ ------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------=------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 --- ---------------- ^- Owner ------------------------------------ BY -` --------------- Title 1 ' - (If 4 than owner) ��DENT USE ONLY APPLICATION ACCEPTED BY ---------- -- ----- --- ---- ------------------------------------------ DATE --- - ---77---1--•�1- - ----------- BUILDING PERMIT ISSUED ------ ------ - - ------ - ---- - ----------- ------------------------------- --- --- -DATE -- ----------------------------------- - ADDITIONAL C MME S-- ---- - ----- ------- --------- - ------ -- ---� - ------------------------ --- ---- ---------------------- --------------- Jk/ z = --- ---- ---- -- ----- �C ----------------------------------------------- - - -------------- rF - Final Inspection bY- ----- -- - ---- ----------------------- ----- -- --- -------------------------------Date - ---� 71 ----•------- JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M