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FO- -R OFFICE- - - USE- - : APPLICATION FOR SANITATION PERMIT 70 -- -- ---- •- - -- -------- Permit No. - ------------------- (Complete in Triplicate) This Permit Expires 1 Year From Date Issued�- ]� Date Issued --_ � -_---_-____- --- l----1. -----_--__ _ --__-- -_ 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 incompliancewith County dinance No. 549 and existing Rules and Regulations: J �_ CENSUS TRACT JOB ADDRESS/LOC�ATIO/N ._� _ _- _-- '- - -- - Owner's Name / --L -- ------ ---- --- ------ -----.--Phone S;? ------ AddressA-t--------- --------- - -- -- -----•--- tY ---------------------------------------------- Contractor's --------------------- /----------- -/----- Contractor's Name _____ __ __ _2_ g o- --- nse #/ ``---- Phone f-- —1-1 -.-- Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ----_--- �_-l� Number of living units:------------ Number of bedrooms -_----__--_Garbage Gri er -__-_--- --- Lot Size - �-1� �ZS-_--------------- 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 ----.----_--_-_-.----_---- gg,, h (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------------------------------------------------ Liquid Depth _--------_-__--_--_---___ Capacity -------------------- Type -------------------- Material--------------------- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -_-___-__--___-___-___ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--_-----__--_---_--_---_ Total Length -----_-____________________ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _-.--.----_----_---_--__---_------.__------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---_-_-__-.___._._.-.--_ SEEPAGE PIT, [ ] Depth -------------------- Diameter ---------------- Number ------___._--__.------— Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well .---------------------------------------Foundation --_--------- ------ Prop. Line _--_.________--_---__ REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- Date ------_-.-----_--_---_-__-___-----) Septic Tank (Specify Requirements) - - ------------------- ---- -- ----------- ------------------------------•-•--------------------------- Disposal Field (Specify Requirements) --- ------ --- '^� - - - - 3`1x-25 '--- P- -------------------------------------------------------------------------------------------------------------------•-------------------------------------- --------------------------------------- (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 ---------l.e'�� - - - - Title ----- -- - ----------------------- (If of r han owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --___ —-------_ S1_ '� DATE __.`--.......------- BUILDING PERMIT ISSUED ------- - - - ------ --DATE ------------------- ---------------------- ADDITIONAL COMMENTS __-- __ _ 0` "' c- ------------ - B- u------- 1 -� -------------------------------------------- - ------------------------;------------------ -------------- ----- --------------------------- -- - --------------------- -------------------------------------------J-------------------- ------------------ -------- - -- - - ------ d Final Inspection by: --- - - - -------- -------------------------- ----------------------------------------------------- --ate - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M