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FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT ---------- - J/,ys' n y (Complete in Triplicate) Permit No. ----------------_ ----------___ This Permit Expires 1 Year From Date Issued Date Issued __3___:_x_3__ 7 Z_ 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: JOB ADDRESS/LOCATION --- J --- - �:-------- ----------- x------_ i---,-_--1-_--.-_-,-1I_-�--.-�k- -t---------CENSUS TRACT --------------_---------- Owner's Name 2-1 r Phone ------------------------------------ Address --- ------Address, ?ti. f -- C - ------------------------------------- - ------ ------ Contractor's Name ---------- -, - __.License #.�'��.�`�` Phone Installation will serve: Residence;"partment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ------------- Number ---------Number of living units:---- Number of bedrooms __� ____Garbage Grinder __ ��-__ Lot Size __L___ tC_�_�_' _ __ :-- ..-- Water Supply: Public System and name _____ - _- -- ------ .................r -- ------------------------------------------------------Private [�' Character of soil to a-depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam "❑ Clay Loam 0 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' `► '_._______ Liquid Depth _ 1� -_______--_ IN __ Size _ __X ___ __� Capacity� d� ��_ � Typet Material___ No. CompartmentsLV ---- = =•---------- Distance to nearest: Well , c________________•_____Foundation ----ZV)_r------- Prop. Line _____?__`_______--• LEACHING LINE No. of Lines - `� -__._______ Length of each line------� _____ ____-_ Total Length - ��--�-�- ----- --•-_-_--- It 'D' Box ----- ----- Type Filter Material ___ sZ_ "_ %. Depth Filter Material _____/1------------------------------- Distance __---_____-•______-•-_______Distance to nearest: Well ---�?e_________ Foundation ____f�C__ ---------- Property Line ___ _ ____ _ SEEPAGE PIT Depth -__ �' _r______ Diameter _- ____ ___ Number ___________________ _______ Rock Filled Yes ( No i❑ Water Table Depth ----------- -l---------------•------------Rock Size ------x Distance to nearest: Well ------fc'�__'---_-___-_---_-__ _Foundation ___l_4 ______ Prop. Line _.._ _ __----------- REPAIR/ADDITION ___-_----REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------)_ Septic Tank (Specify Requirements) --------________._ Disposal Field (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- ----------------------- ------ - ----------------------•----------------------- --------------------- - - - ------------------------------------------------------------------ (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 ollowing:"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 -� 4i' 1Title - � (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _______-___• / ___ DATE __. __ 3 BUILDING PERMIT ISSUED --___ _ --------- ---- DATE ----------- ADDITIONAL COMMENTS _ 3 ? -- - ---------- ---------------- -------------- ------------------------------------------------- ------------------------------------------------------------------------------- ------------------------ ----------------- - - ----- ------------------------------------------------------------------------------------------------- Final Inspection b p Y Date _ 7 --------------- SAN JOAQUIW LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ('