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OR OFFICE USE: APPLICATION. FOR SANITATION PERMIT -------- ----- - ---------------------------------- - (Complete in Triplicate) Permit No. ---------------4-n-0----------- This Permit Expires 1 Year From Date Issued Date Issued s,AO P Application is hereby made to.the San Joaquin Local Health .DistLict 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: _ - -- __ . . m -CENSUS-TRACT --------------- JOB -ADDRESS/LOCATION ..7--1-W--- � -� ---___-._- Owner's Name ----- ---eyn- -_-.-_ 9L _ - -- ---------- - --- ------ Phoner�. f� - Address ----------------- Z .---------- ---- --Y-------- Cit- G-z/ia 9- ------------------------------------- Contractor's -- ------------ .------Contractor's Name _� _ - ------'--------------------- icense # Phone _� '74_-$A Installation will serve: Residence [2'Apartment House Commercial ❑Trailer Court ❑ Motel ❑ Other -------------------- ------------------------ Number of living units:_________ Number of bedrooms ____ Garbage Grinder -_-__"-___ Lot Size -__ ___ _-._'__-..-__ Water Supply: Public System and name -------------------------------------------------------------- -------- ------------------------------(•-------Private Character of soil to a depth of 3 feet: Sand�r Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ ' yes,type ----------------------------- (Plot - ___--(PIot 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,) �0 PACKAGE TREATMENT [ ] SEPTIC TANK�W Size-_ --_V--%� ��'�Q_�_ Liquid Depth ------ ?Capacity :_/ _---- Type '- -___-- MaterialLu�� - No.. Compartments �� - ! Distance to nearest: Well __i_______--els �_---_---_-Foundation _ Prop. Line -_�1iQ..... _-___- LEACHING LINE No. of Lines --------- ---------- .Length of ach line---------7_Q_ Total Length -- ........ 'D' Box ----/----- Type Filter Material -----14�---------Depth Filter Material ---------1-9........................... Distance to nearest: Well --- ------------Foundation .____)/_[?___-_______ Property Line. ......... ,SEEPAGE PIT [ ) Depth ____________________ Diameter --------- ...... Number ------ --------------------- Rock Filled Yes '❑ No C] Water Table Depth --------------------------- ---- --------------Rock Size -------------------------------- Distance to nearest: Well -------------------- ---- --------------Foundation --------------------- Prop. Line ------------- ........ l REPAIR/ADDITION(Prev._Sanitation Permit# --------------------------- ---------------- Date -----_-----_---_-----__-____----_) Septic Tank (Specify-�Requirements) ______ --------------------------------------- Disposal Field (Specify Requirements) �_ ---_-f -- -- _ -` - A --------------------- - - - - - - - (Draw existing and requir4d 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: 4 "I certify that in the performance of the work for which this per it is issued, I shall not employ any person in such manner I 's Compensation laws of Califo nia." as to become subject to Workman , Signed ------------ -------- ----------- ----------------------- - »J Owner BY --------- f -e---------- i ----------------'--- Title -------- ------- (If other than owner) t a r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -----40- ^t „"„'---•------------------------------------------------------------ DATE PrP BUILDINGPERMIT ISSUED ------- ------------------------------- ---------------------------------------- --------------------------DATE------------- ------- ADDITIONALCOMMENTS ----------------------------------- -- ----- ---------------- - -- - - --------------------------------------------------- ------ ---- ------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ---------------------------------------------------------------- --------------------------------------------------------------------------------------------------------- --------------------------------------- -- - - - - - - - - - -------- - ------------ - Final Inspection by: ------- Date ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M