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FOR OFFICE USE: - --------- ,,.�.Cf_ -"APPLICATION FOR SANITATION PERMIT ---- 9� l.��a / 3 (Complete in Triplicate) Permit No. .��-_ 0% _-----_------ � This Permit Expires 1 Year From Date Issued Date Issued I�= --------------------------- 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 22compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ---. - --_ ,d- --- ------& ---- -- ---------------CENSUS TRACT --------------•--•----,--- Owner's Name -•--------------- - - ------ - rt---------------------------------- ------Phone -- Address ------ ---------------------- - ---------- --------- -----------. Citv----------------------------------- ---------------------------------- ---••- )._ Contractor's Name ------------------ --------- �-t " ° ----- ------.License-# ----- Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other --------------------- ---------------------- _ Number of living units.-_1----- Number of bedrooms7�Garbage Grinder ------------ Lot Size ------ O Water Supply: Public System and name ----------------------- -----------------------------------.-Private ❑ Character of soil to a depth of 3 feet: Sand'E] Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe'�L 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.} rn? ! NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer',is available within 200 feet,) "1 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.fine-:T----------------- Total Length -----------.---------------- D' Box ------------ Type Filter Material _----_- ------------Depth Filter Material --------------- ---.--•---------------..--- Distance to nearest: Well --.--- --------- --_(Foundation ------------------------ Property Line. -_----------------_:._- 1 SEEPAGE PIT Depth -------------------- Diameter --------------µ}Number ---------------------------- Rock Filled Yes ❑ No i❑ ..- .., Water Table Depth -------------------------------:`--- ------------Rock Size -------------------------------- Distance to nearest: Well ---------------------------•-------------Foundation -------------------- Prop. Line -----------.--.•-•-.-. REPAIR/ADDITION(Prev. Sanitation Permit s# ------------------------------------- ------- Date ---.-_--_--_-------___-__--:-----) Septic Tank (Specify Requirements) ---- --- ----- = -- ----------- - Disposa Field (Specify Requirements) - `_-- ------------- -------- --- -----�---- - I - ----- ----------- Draw ex - - ` ------------------------------------------------nd re aired ad`:-------- -- --------------------------------- --------------- -- -->-------------- i { g q dition 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: . _.-- ------ -- t T "1 certify that in the performance of the work for which this permit is issued, 1 shall.not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------- ---------- ----------- --.------------------------------- Owner BY ----- - ----------------------------- --------------- ----- Title i -------------------- ------------ -- of er th owner[ FOR DEPARTMENT USE ONLY f1 APPLICATION ACCEPTED BY -.'W ------------------------------------------------------ -------- DATE 1I_f 4A - •6-k--------- --------- BUILDING PERMIT ISSUED = == - -== === ----------------DATE -- ------ --------------------- ADDITIONAL COMMENTS . -- , ------'-- ----------------------- ---------------- ---------------------- ------ --- ---- -- ------ ---------------------------------------------------- -------------------------- ---------------------------------------- -- --------------- ------------- --------------tl ----------------------------------------------------------------------------- --------- DateFinal Inspection by: ---- -----�--- ------ � ------7. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M I`1.