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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------4-no (Complete in Triplicate) Permit No. 3_____________ This Permi'Expires 1 Year From Date Issued Date Issued .57-4. _V-13 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 Coun4 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION -------so..------.g------ 5,71-----------------------------------CENSUS TRACT, -------- ------------------ l�l/�1 f'-----411X--------------------------------- u �Z�'/7 -) Owner's Name � ------------Phone ------- - -- ----g------------ ----------- - ------ - -- ---- Address ----11,2 ___W------til/,1cSP_Al _G�' Contractor's Name -----------------------------------License -------- Phone Installation will serve: Residence ['Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other --- Number of living units:---/_------- Number of bedrooms ._�_---Garbage Grinder -W0--_ 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 roam ❑ Hardpan ❑ Adobe R 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK [ ] Size_-___----_____________________-------_____a 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) ----------- S- ------------------------------------------------------------------------------------------------- - ------ ----------------------- ------------------ (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: "1 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 _ 6 BY --------------------------------------- ------ Title ----- --- - ---------- --- -------- - - ---- ------- (I other than owner) -- ------------------------------------- �_% FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY______ _________ ---------- ----- -- DATE ---- -- --- -------- --------------- � BUILDING PERMIT ISSUED __ _ _ --------------------------------------------------DATE --------- ADDITIONAL COMMENTS ____ ------------- -------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- -- - - -- -- --- ------------- --------------------------------------------------------------------------------- ------ ---- Final Inspection by: -___._ __ _ -- ---- --- --- - ------------ ------------------------------------------------- _- - - ----------------Date ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M