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FOR FFICE USE: • APPLICATION FOR SANITATION PERMIT ---------:`----------------- 1 Permit No. (Complete in Triplicate) --------- 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 .__- ®��----- --------------------------- -1---��r -----------------CENSUS TRACT ----------------------- Owner's Name _ _ � �/ r' ----------------------------------------------------- -------------------Phone -- ��-¢----- --------. City ------- l 'T ' 6 Address _l.l �1� _ ,coo _ /� S__ �' ��- - Contractor's Name - ---``--`---------------- ------------------------------------------License # ----------------------- Phone .............................. Installation will serve: Residence�&Apartment House❑ Commercial`❑Trailer Court ❑ Motel ❑Other -------------------------------------------- __ ----------------- Number of living units:____ _____ Number of bedrooms _-__`___-_Garba a Grinder ____ ---- Lot Size _______________________________-___----- 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 N Fill Material _______ ---- If yes,type ____________________________ (Plot plan, showing size* lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic or seepage pit permitted if public sewer is available within 200 fee PACKAGE TREATMENT SEPTIC TANKSize-------� _ __.. p y . c Type o. Compartments — Ca Capacity �- f T e --- ---- ---- atenal ��`% ------- -- Distance to nearest: Well __ _ ___--- dation __ __ Prop. Line __.___ - � Q --� t LEACHING LINE [ ] No. of Lines -----/---------------- Length of c line__-______ _ _____-___-__ Total Length ------ -- W k -,- i D' Box -___�_____ Type Filter real _ - �-:____Depth Filter a ____ `_______.............. 1_7s� �r ------ Foundation --- ----- ---- Distance to nearest el ____ Property `. •-•--- ON SEEPAGE PIT [ ] Depth _-_ -------------- Diameter _______________ _ Number _________-________ ________ Rock Filled Yes ❑ i❑ VVa er Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well __________________________________ ___Foundation --------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# .------------------------------------------- Date ---------------------------------- Septic _______-_-_-----_------__--______Se tic Tank (Specify Requirements) ______ _rC ___ ____C c. 9 __ - _-_ _ Disposal Field (Specify Requirements) ------ ` f.``-`...... - --------�Cs7------ ��_ ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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/syb)ectto rk an's ompensati.on laws of California." Signed ---- - ----- ------- ----`------ ----------------------- Owner BY ----------------------------------------------------------------------------------- -------- Title -------------�w+to--------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ �_- _-__ - �._ DATE Al - -- ------------------ BUILDING PERMIT ISSUED -------------------------------- ew olAlt7t ------------- ----------------------------- ADDITIONALCOMMENTS ------------------------------ ---- --------------------------------------------------------------------------------------- -----=---------------- ---------- ------------------------------------------------------------------- ------------------------- -------------------------------------------------------------------------- ----------------------r� ------------------------------ ---------------- - --------------------------------------------------------------------------------------------------------------------------- --- --------------------------------- - - - - ------- -- --------------------------------------------------------- f� Final Inspection by: �- ------------------------------------------------------------------------ Date -C6/" -r r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M