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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / � ... Permit No. ------------ f (Complete in Triplicate) • P P This Permit Expires 1 Year From Date Issued Date Issued ----------------- -- r ----------- _ ------------------- ----.---------_----- Application is hereby made to the San Joaquin Local Health District for a permit to cons rut ct-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 .--- .v-4D------ ' ---- -��1'!-moi-=-------------------------CENSUS TRACT --------------------.•---- f Owner's Name ----- ------------------------------------------ ------------------.Phone --------------------------•--------- Address ........5'a---/77�,Q------/-------- -------=------ -----------------. city � �7/gi ��;f71 ----------------------/f------ Contractor's Name --------/1 +7 � 1-_�_ff � = License #�f�_/ •� - Phone 7- 11 ---•. Installation will serve: Residence Apartment House❑ Commercial: Trailer Court :E] ' Motel ❑ Other --------------------- -------------------- -- Number of living units:--- ----- Number of bedrooms,.-------Garbage Grinder /1)P--- Lot Size --------•--- '"'f 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 ❑ i,, ,Adobe-❑ Fill Material ------------ If yes, type ----------------------- -- `t (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 permited if public seweLis 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 ❑ WaterTable Depth ------------------------------------------------Rock Size ---------------------1---------- Distance ------------------ `----- --- Distance to nearest: Well ---------------- -----------------------Foundotion -------------------- drop. Line --------------•------- Y REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------.--:--------:---Septic Tank (Specify Requirements) --------------- - --��--�---W - ------------------------------ "- -T---�--_--�---_ ------------------------- ze— W- -7/ __7------------------------------------ Disposal Field {SpecifY Requirements) ----------- --------------------- ----- -------------- -F -z: ` t ------------------------------------------------------------------------------ (Draw existing-and-required-addition-ori 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,�p-ermit is issued, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of.- allfornicil." , . Signed --- -- --------------- _ . �4Ow` her- _ _ Ttle ----- ` h imI-------------- ---------------. ---�-BY - _ (1f othe an owner) FOR DEPARTMENT U�E ONLY ..t,F, ` R--. ---CP-�. APPLICATION—ACCEPTED—BY— t=� ._:,_ ` : ------ DATE ---- ------------- -------------------- DATE ------------- ----- BUILDING PERMIT ISSUED ---- -- --------------- -- - -------- ADDITIONAL COMMENTS --- ---- -----=--------------------------------- --------------------------------- ° -------------- - ------- ------------ -`------------------ ----------------------------------- ----------------- ---------- ------------ ------ ---------------------------- = -- --- ----------- ------ ------ --- ---- ------------- -^--^- - ----------------------- -------------------------------, ------------------------- Final ------------`---------fi r Final Inspection by: - f�G------ -- - - --------------------- -------�-- - Date --------- f SAN JOAQUIN LOCAL HEALTH 151STRICT E. H. 9 1-'68 Rev. 5M.