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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------- 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. 54499-and existing Rules and Regulations: JOB ADDRESS/LOCATION ------- 'sf /V'/ ---------CENSUS TRACT __________________________ Owner's Name ly-� 'S e /_ '/ ---------------------- ------------------------------ --------------------Phone Address �cI Z3_-2---- - - ----- -- _ _V ----------------- - City s//''xl � ----------------------- 1L owe4-//e------------------------------------.License #va-, __d---- Phone Contractor's Name ____ __. ,�__.-_____ Installation will serve: Residence [Apartment House,[-] Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:_____------ Number of bedrooms,;T�k------Garbage Grinder _________ Lot Size _-__________-_____________________________ Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'[0 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.) rr\4� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) W PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -----------------.__,.____ V Capacity -------------------- Type --/he --------- Mate 'al--------------------- No. Compartments _................... . Distance to nearest: Well __ __.____--__•_- _____--Foundation --------- ----------- Prop. Line ___--_--____--_-____-_ LEACHING LINE [ ] No. of Lines ______________________ h of a line--------------- _____--__ Total Length ...___._.__..........__._... 'D' Box ____-_.__. Type Filter Mal ____ ______________Depth Iter Material -______--_-___-..-.:--____------.---_.--.- Distance to nearest: Well _.___. __.__. ___ Foundation __ _____------------- Property Line _-______......... ...... SEEPAGE PIT [ ] Depth ______-_-.-______ Diameter __ _______ Number ___ ________--._____..__- Rock Filled Yes '❑ No Water Table Depth ---------------- ---------------•--------R k Size --------------•--•-------------- Distance to nearest: Well ____ ________________________Foundation -__-..__---____--_.- Prop. Line ...._...._.._.._.___._ REPAIR/ADDITION(Prev. Sanitation Permit# --------------- --------------_----- Date ----------------------------------) Septic Tank (Specify Requirements) --------------•- --------------;------------------------------ --;------ ---------------------------------,---------------------- Disposal Field (Specify Requirements) - ------- --------X.=' 11-X-le -------------- ----------------------------------------------------------------------------------------1,� 1ltt�� c tS l .ryl --------------------------------------------------------.--- ------------------------------------------------------------------------------------------------------- -•-------------.------ (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 Wo kman's Compensation laws of California." Signed -- ---- ------- -------- ------------- - s---- - ------------------------------------ Owner By ---- --- - n --wn---- --- -- ------- ------------------------ Title --------------------- --------------------------- -------------------- (IfJFPother than owner R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---------------�------------------------------------------ ------ DATE ---- '/ BUILDING PERMIT ISSUED ____________________ ____ __ ATE ______.__ _... . --___--. -_ --- ADDITIONAL CQMM NTS ---- S ��= " '''� _y'r'-' %Y ! 6P � ' - `^ ��' / --r----- -- t '- ------- --- ------- - ------ A_,0,VV----------- `? 3------- ." 1 R ----- -- --- ----- ----------- - - - ---- --- -- Date ---1-2---- -1 Final Inspection by: ------------- - ---- - ----�-`- ---------------------------------------------------------------- --------- --------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT G72) E. H. 9 1-'68 Rev. 5M