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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . Permit No. !1-~-l__�7 ------------- ----------------------------------------- (Complete in Triplicate) J��j Date Issue��'�(__... ------_----------- _ } [/ v--------------------- This Permit Expires 1 Year From 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 pplication ism e i1� compliant with Count yy��rdinance No. 549 and existing Rules and Regulations: �� e� / ® . ,or-,Tfo tom` �a�- JOB ADDRESS/LOCATION 1ll�_�71_-1�---�---/7�' : '--��---'"�►� 'T�l��v' £E��_CENSUS TRACT ____ .' Owner's Name ...,��----------- ----------------------------------------- ---------- Phone . �r Address ----- /__7o_- /I `� ---5 ---------- -- ` City MAW Ccs------ ------- ---------- .............. - -------------------- - ---- --- Contractor's Name --- ------------------------------------------------ License # 3��e` Phone . Installation will serve: Residence &_Xpartment House❑ Commercial ❑Trailer Court !❑ Motel ❑Other -------------------------------------?........ Number of living units:_-- ----- Number of bedrooms _3-------Garbage GrinderAK- --- Lot Size ? `r c.P S--------- 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 pit permitted if public sewer is available within 200 feet,) �\ PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size-----------------------------------_1,-------- Liquid Depth __--..-____....-_- ------- Capacity ----- -------------- Type -------------------- Material------------------- No. Compartments _.......-------.:.... Distance to nearest: Well,, ____________________---________-:__foundation ---------------------- Prop. Line -----------_-------- LEACHING ---_____- .. ,_-__-.-LEACHING LINE [ ] No. of Lines ------------------------ Length of each .Pine- -------------------------- Total Length ,____---__-___------------- - 'D' Box ------------ Type Filter Material ------------------<_Depth Filter Material -------------------------------------------- Distance .-- -------------------------------------- Distance to nearest Well ------------------------ Foundation --------------- -------- Property Line ........................ SEEPAGE PIT [ ] Depth _,.;------------ -, `Diameter _____________ Number - --_----_ . _-_____---- Rock FiIW Yes Q No WaterTable Depth -----------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------- .....Foundation _-__--__..__ ------ Prop. Line ...................... REPAIR/ADDITION(Prey. Sanitation Permit# -------------------=----------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------------- --------= ----- / • ------ Disposal Field (Specify Requirements) - _ � , --------------------------------- .----------------------, ------------------------------------ ----------------------------------------------------------------------------------------------------------------_------- (Draw existing and required additi"on'on reverse side) I hereby certify that I have prepared this application and that the Work will be den* 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 is;4ed, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California. Sign - --- --- -- --- -- -- -- ---------- ---- Owner BY 7 '- - . . --- ---- ;title __ .!_ ` _20------------ (1f other than o �t FOR DEPARTMENT USE., ONLY APPLICATION ACCEPTED BY -------1--f-A-- --------- ---------- ----- ------- ----- -------_. DATE l��_ -- --- --------- BUILDING PERMIT ISSUED --- --=-- - - - --------------------- DATE ---- - __-- ,;. ----- ADDITIONAL COMMENTS-_` ' - _ &UL-` -------- ------ - --- -- -------- ------------------------------------- ----- ----- - --- --- - --- j Final Inspecti --- --- -- ----- ----: Date _ / 1 SAN JOAQUII 'LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M >