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FOR OFFICE USE: APPLICATION F6R 'SANITATION PERMIT --------�r:�---r (Complete in Triplicate) Permit No. _. _..-.__.. -- ---- ---- ------ ------ This Permit Expires 1 Year From Date Issued Date Issued _ 7=f-�� 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/LOCAT N .___. Q4J�_____ __ ___ _____ ( ! ' - 1-- '1-f_. ___ _ --CENSUS TRACT -------------- ------------ Owner's Name ----- Phone ------ -------------------- ----- - -------- ------ ------- Address ----------------- 4w-- -- -t Cit �_ �0 �p Y ------ Contractor's Name ------------V44ri,ag�f_---- ------ ------ ------------ ------License # --------- Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court 0 / Motel ❑Other---------------- ---_----_-------------- Number of living units:-----1__--- Number of bedrooms - ------Garbage Grinder ------------ Lot Size ---1_4<�. ---------------- Water Supply: Public System and name ---------------------- ----------------------------------- -------- •--------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loa rrA Hardpan ❑ Adobe'❑ Fill Material ------------ If Ayes,type ---------------------------- (Plot ____-__________________(Plot plan, showing size of lot, location of,system in relation to wells, buildings, etc. must be placed on reverse side.) O NEW INSTALLATION: {No septic tank or seepall ge pit permitted if public sewer is available within 200 feet,) Q PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-----------------------------------_------------ Liquid Depth -------------------___-__• Capacity 3. -- ;---..---IyPe -------------------- Material---------------------- No. Compartments -------------...-- Dista"nte to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... LEACHING LINE No. of ,Lines ___,_____ [ l Length of each line---------------------------- Total Length -------- ................... 'D' Box ____,...__ Type Filter Material -------_-_-----___-.Depth Filter Material _____________________________________ Distance to_neares#: Well ----.------------------- Foundation ----- -' ------------ Property Line ........................ SEEPAGE-PfT [ ] Depth __________________ Diameter ------------ Number ---------------------------- Rock Filled Yes '❑ No i❑ Water Table Depth > =---- ---------------------------t_---__Rock Size ------------------t-------------- ,' - Distance,,to negrfst: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------_--- REPAIR/ADDITION(Prev. Sanitation Permit0---------------------------------------------- Date _-__--______•_____-_____________) Septic Tank (Specify Requirements) ------------------- -- ------------ -- - --- ---- -- ---� Disposal Field (Specify Requirements) -------- - � y ' a ---------------------------------------------------- ----------------------------------------- ----------------------------------------------------------------------------------------•- (()raw existing and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------:--------------- ------- --------- - --------------------------- Owner BY --------------- - i ------------------------• Title --- R --------- ----------------- -------------------- (If of r than ner) /)FQJ DEPARTMENT USE ONLY ~ APPLICATION ACCEPTED BY------ 7----------�--------------7-----------------' --------------------------- ------------------------------. DATE 10 ^-------------------- BUILDING PERMIT ISSUED --------- --- -- -- --------------- '-- .-.--------------------------------------DATE _-=------------- ----------------------- ------------------------------------------------I--------I -------------------------- -- ADDITIONAL COMMENTS _________ ____ 1____ --- ----------------------- ----------------------------------------------- --------------- ------- ----------------- --------------------------------------------------- ----- ------ -------------------------------------------- ----- ------ ------ - '-- Final Inspection by: �-- -------- Date �£l / _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M