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FOR UFFICE-USE: APPLICATION FOR SANITATION PERMIT ---------------- .- (Complete in Triplicate) Permit No. ___31 _--_-____-. 44 ---------------_--------------------------_--------------- This Permit Expires 1 Year From Date Issued Date Issued _yI. 1T%..... 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/LOCA 11TION "--------------------------------- CENSUS TRACT_------------- ( - Owner's Name ----``11. _ft_x _ !1 - Phone Address --- }------aJ- =t/°� �'�t ------------------__..... City�11Y&Xi if�------------------------------------------ Contractor's Name <� -----------------------------_____-___-License - Phone .` a Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other - --------- ----------------- Number of living units:---P______ Number of bedrooms ---------Garbage Grinder ------------ Lot Size _l__ '��_ ________________ 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 pint permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK�[ ] Size-------------------------------------------- ___ Liquid Depth -_________-____-____----_ SON Capacity -------------------- Type -------- ---------- Material------- -------------- o. Compartments ............ ......... Distance to nearest: Well ________ __________________________Foundation ___ _____-______-_ Prop. Line ...................... LEACHING LINE [ ] No. of Lines __________ Le gth of each line_______-___________- ___ Total Length ----------- ............. U 'D' Box ___________ Type Filter Ma rial ___________________Depth Filter aterial��____-_____________-____----------_---._--- Distance to nearest: Well ________ _____________ Foundation ___________ ---------- Prbperty Line .__............_.....__ SEEPAGE PIT [ ] Depth _____ Diameter ---------------- -- Size -- ------------------f-•------- ) Distance to nearest: Well _______ _____________________________Foundation __ _ ::___.;;__ _ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit 5# ____________ _ _ ______________ Date ______.___ Septic Tank (Specify Requirements) -r ----------- ----------------------------------------------------------- 1 --------« ---'------------------------ s � -�Disposal Field (Specify Requir1�d-----------/- C --------------------------c ----------------------------------------------------------- ------------------------ -- - ------------------------------- - ----------------------------------------------------- IfDraw existing and required addition on reverse side) I hereby certify that 1 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 ------ - C - = ----------------------------- Title ------------------------ -------------- ---------- (If other than owner ��FOR DEPARTMENT USE ONLY �APPLICATION ACCEPTED BY ---- ----`- 45 `" .---------------------------------------------------------------. DATE ------------------- BUILDING PERMIT ISSUED --------------------------- ------------------------------------------------------------------------------DATE ------------------------------------------ ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------- -------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- 1- __ _ - - - - - --------- -- - -- --------- ----------------------- FinalInspection b ✓---- -- -- _------------------------------------------ - -------------- -- ------ -- ----Date --- --2V-------------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M