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i FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _ ___ Q `� ------------------- ---- - /( Date Issued ----------------- __ ________________._ 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: ' 1 1 ____� U ---- --.- ------- -- ---_CENSUS 3,9=.21 --- - --------- Owners Name A-----JOB ADDRESS/1_00 jWTRACT -__f ¢ -0.�/� - Address --------------------- ------------- F --------------------------------. City` ��1�"�� ---------------------- Contractor's Name ___ ,�.�_..... _____{!`1_ _ f�'e__________________________.License - -3 ,Phone Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other --------------------------------------- Number of living units:___________ Number of bedrooms ______Garbage Grinder __________ Lot Size /__ i?.�1 _-------------- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Uf Character of soil to a depth of 3 feet: Sand'K Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ___________ If yes,type ---------------------------- (Plot ________________________(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �n NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f I Size-----------------------------------.------------ Liquid Depth ________-----_-..-,___- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... Distance to nearest: Well ------------------------------------Foundation _'__________________ Prop. Line __-._______-_------ LEACHING LINE [ ] No. of Lines ________/____________ Length o each I' e______/,E?__Q__--_____ Total Length ,_/. f ...... �l D' Box ------------ Type Filter Material C__ __ '-__ _Depth Filter Material __` __________________________________ Distance to nearest: Well ------ Foundation ___�_O__r________ Property Line - ................ SEEPAGE PIT [ J Depth ________________ Diameter ______________ Number ------ --------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------------_-------------------) Septic Tank (Specify Requirements) ------------------------------ ---------------------------------------------- - --- ----------- ------•---------------- ------------ Disposal Field (Specify Requirements) -------/_.�2_Q_-----��______4--io �_C�_�1______Li-w_,ir-----tib------------------- f__. � ld �---------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (Draw 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed - a --- ----- --- 1------I-- --------------------------- Owner c ?--------------------------- Title ------------------------------ ------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------1'---1-R_,U1--------------------------------------------------------------------------- DATE .. - / BUILDING PERMIT ISSUED ---------------------------------------------------------------------- -----------------------------------DATE ------------- ----------------------- ADDITIONALCOMMENTS --- -- ------------ - --- ------------------------------------------------------------------_---------- --------------------------- ------ ------------------ ---- - --------------- - ----- - - - --------------------------------------------------------------------- ------------------ --- ---------------------- - --------- - ---------- -- - - ------------------------ - -- ----- - ---------- --- --- -- ------------------ -------- --------- - - -- -------------------------- ------- ----- -- f Final Inspection by: ------ ----------------- Date - --^ ------ --- --r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M