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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. _ (Complete in Triplicate) ----------------- -7 This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATIO -_l___�-�-f-------�-------- �- -- _4-n ------------------CENSUS TRACT ----- c�"` Owner's Name ------------ -- ------- --- ��"'- ---------- --------------------------------Phonee_�`�-1_ 10 Address ----------------- / 2Aa,_. a----- -•------ �.._.__. City ----------------------------- Contractor's Name ------------- --------------------------License #LLW_J�------- Phone 7n6_"-------07-•---- Installation will serve: Residence`(Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units:-- of bedrooms ___v.Garbage 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'❑ Fill Material ------------ If yes, ype -__________________________ (Plot plan, showing size of lot, location of system in lation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit ermined if public sewer is avail ble within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size__________________________________-___ -_--__ Liquid Depth _-____---_-------____-_-. Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ............... Distance to nearest: Well _____ _______________-_.-________.Foundation ___ -____-_.__-_____. Prop. Line -...____________--..._ LEACHING LINE [ ] No. of Lines ------------------------ L ngth of each line- __________ _____ Total Length ,_-__.._...._.......__._... \ 'D' Box ------------ Type Filter Ma erial --------------------Depth Filter aterial -------------------------------------------- Distance to nearest: Well ________ _______________ Foundation ____ --------- --------- Property Line -___.._-________--.-.--_ SEEPAGE PIT [ ) Depth -------------------- Diameter ---------------- Number ------------------ --------- Rock Filled Yes ❑ No CO] Water Table Depth --------------- ----------------------------Rock Size -- ------------------------------ Distance to nearest: Well ________ ____________________________Foundation ------------------ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- -------------------------- Date _-______-___ ______....__._______) SepticTank (Specify Requirements) ------------------------------------------------------------------------- ------- -------------------------------------------------------- ------------------------------------------ ,,() �L r Disposal Field (Specify Requirements) -----------1 U'-------7 � -- --- ---------- ------ --------- -C'Z 5---------� X -,-----`' ''---------�=(-----------------------------=------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 Workman's Compensation laws of California." Signed -------------------------------- ------ Owner By --------------- -- --- --- ----- ---------Qlu&-------------------------------- Title ------------------------------------------------------------------------ (If of r t owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------/--tJ?_,&A---------------------------------------------------------------------------- DATE --- BUILDING -BUILDING PERMIT ISSUED - < - --DATE ------------------------------------------- A--D---D--I-T--I-O---N--A---L- COMMENTS ----- ------- --- ---P_ ------- ------------------------ ---2'- ---------I---�-------- ------ --- --------------- - --------- ----------- - -- ------- - --------------------------- -- ---------- - ------ = ------ • ---- - - ----- ------------ -- Final Insp -- ------ ------- -Date - .p.. SAN JOAQUIN LOCAL HEALTH DISTRICT G E. H. 9 1-'68 Rev. 5M �