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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------------------------------------------- (Complete.h Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued ___. 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 - - -- ----- -------- ------------CENSUS TRACT -------------------------- Owner's Name - � `�-/SC1 �/� a / Rr �_'4 ,,��jj��-�------------_Pho�n+e j`4� t �1�� Address --- /¢ `/US__ L city __ 1'C ., t Ct`��f L�^ � Contractor's Name ------------t1I/VAff-4--------------------------------------------------License # ------------------------ Phone ------------------------------ Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other _j0j4_Ckj_/1<;;------75A �, C,��/��Cit6j)T- Number of living units:__________ Number of bedrooms ______-_--_Garbage Grinder ------------ Lot Size ------------_------------______-___-_----- Water Supply: P- lic System and name ------------------------------•--- ----------------------------------------------------------------Private ❑ Character of soi to a depth of 3 feet: SaY 1r)�; =S;�t4D Clay E] Peat Sand Loam ❑ Clay Loam Her"phO 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 [ I SEPTIC TANK [ ] Size----- __4?_.0----<;_ _�---------- Liquid Depth -------------------------- Capacity -------------------- -_______________________Capacity_---______________- TypeN_�---_ MaterialCDAIC070%. Compartments Distance to nearest: Well -__-___________________________Foundation ------ Prop. Line -______-______.___-__ LEACHING LINE [ ] No. of Lines ------------------------ LtngtN of each line---------------------------- Total Length ,___-_--__----------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ___-_-_.-__-_-___------------------------ Distance to nearest: Well -------------- _.___.__ foundation ___- --------- Property Line ------------ .......... SEEPAGE PIT [ ] Depth __- _ _______ Diameter/0-,X�10_ Number ---------------------------- Rock Filled Yes © No i❑ Water Table Depth ------------------------------------Rock Size -------------------------------- Ja Distance to nearest: Well ________________________________________Foundation -.------------------ Prop. Line ____--_-_..._.--.-_-. � REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ___-__--__-_____-_-______________-) Septic Tank (Specify Requirements) --------------------------------- ------------------------------------------------------ •--------- ------------------- r 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'donein 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 becomes lett to Workmar,�n''ss ompensation laws of California." Signed . --- �/^fiOwner By ---- ----- Title ------------------------------------------------------ (If - - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY G- - ------ ----- ----- ---- DATES . BUILDING PERMIT ISSUED __/ a/'«_L_ 1 _ _1____ ADDITIONAL COMMENTS "":_ _A _ El.. 1_- -____DATE �_.�_�� .._�`�� - ------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ------ ----- ---------- ------------------ ----------------- --------------- ------------------------------------------------------------ _ - ----------------------- Final Inspection by: -- L°= - --------------------------------------------------- ate --�� ) SAN JOAQUIN LOCAL HEALTH DISTRICT N� E. H. 9 1-'68 Rev. 5M