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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: -------------------=---------- ------------------ {Complete in Triplicate} I --------------------- -- -10 -- --- ------------------- ---------------------- -_---- 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 incompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION ._-/ --- ----- - CENSUS TRACT -------------•.----------- Owner's Name .----- LQ- - --X11_-"-'---------•----.- - --- ----- Phone 7-41' Address -------- �lv aZ - _ '' ----------- City _ "� ------------.License # __ �y_��__ Phone�-------------------------- Contractor's Name _ ---- - ----------- ----- Installation will serve: ResidenceXApartment House°❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------- ----------- f Number of living unrts:__l-_--- Number of b Brooms __-�_ - Garbe Grinders------------ Lot Size _�__�--�------��------•- Water Supply: Public System and name ---------------- -�� Private Ela Character,of soil to a depth of 3 feet: Sand'❑ Silt Clay .,❑ Peat F1Sandy Loam ❑ Clay Loam 'F 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:[ ] Size---------------------------------- - -' Liquid Depth -------------------- Q Capacity Type -------------------- Material---------------------- No. Compartments ---- . ---------- p tY ---------- --•-_ Yp 4 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 0Water Table Depth ----------------------------------------------- Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------. --------- REPAIR/ADDITION(Prev. Sanitation Pe'rmit# ------------------------------------------------------------------------------- Date ------------.-;•--•----------------1 l Septic Tank (Specify Requirements) ------------- -------- ------------------------------------------------ --------- ----- --------------------- E - Di posal Field (Specify Requirements) �- ---- -- !` aQ_•--------------- ------------ --------------------- --------------- ----------------------------------------w--------------------------------------------------------------------- (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 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 b"Me s b;ect to or an's Compensation laws of California." / ''------- ---- -- Owner Signed ---- ------ ----- -- - -------— j---, BY ------------------------------------------------------ ------ --- Title -------------------------------.._..------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ------- -------'--- - ----------------------------------------- ------. DATE ? BUILDINGPERMIT ISSUED ----------------------------------------------------- ----------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------------ ------------ - ------------------------------------------------------------------------------------------- ----------------------------=------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ - - - ------ ----------------------------------------------------------- --------------- Final Inspection by: ---- -- ----------------------Date __��`5------�--- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT i - ft- H. 9 1-'68 Rev. 5M K.. 4