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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT ---------- _/ -- _/o'a- W— �� (Complete in Triplicate) Permit No, 4 ______3_7_. ------ ------ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made-in compliance with County Ordinance No. 549 and existing Rules and Regulations: -- ----CENSUS TRACT -------------------------- � JOB ADDRESS/LOCATION ._-- �� -�-------_- ,.�-�.r.A..---- ��----------- -- �� � 1' 1 . Owner's Name Phone `f --------- Address -- ------ ... City = --------------------------------•------ ---------------------- �j i Contractor's Name 11?----_--------License # Phone i Installation will serve: Residence q Apartment House ❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:--- ------ Number of bedrooms _-A------Garbage Grinder ;*.e>----- Lot Size _/447___ x.-•>________________ 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 ❑ Adobe [jFill 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,) �n PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ___-__.------------------. 1 Capacity -----------------•-- Type -------------------- Material---------------------- No. Compartments ------ -_-••- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------•........ .-.-- LEACHING LINE [ No. of Lines -------------------- L€ngth 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❑ WaterTable Depth ------------------------------------------------Rock Size ------- ------------------------ Distance to nearest: Well ----------------------------------------Foundation ----------------- Prop. Line ------------------_.__ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) Septic Tank (Specify Requirements) ---- ----``----l---------------- --------- -- ------- -----------------------------------..--------------------------- Disposal Field (Specif Requirements} 7` - 6. s --------- 3-a-A------------------- ------------------------------ ----------------------------------------------------------------------------------------------------------------------- ----------------------- (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 become subject to Workman's Compensation laws of California." Signed ----� -- -- ---- -�.C;------------- Owner 01 title --- By r(If oth�than ow r) - -- --- -- - ---- FOR D PARTMENT USE ONLY APPLICATION ACCEPTED BY ----- DATE __.._7'"'/I_6Y----------- BUILDINGPERMIT ISSUED --------------------------------- --- - ----- ---------------- --------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------- -------------------------------------------------=--------------------------- ------ ------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ --- - --- ---- -- ---- ------ - Final Inspection by. -- `k- ON------------------------------------------------------ --- -- - - ---- ----.Date ----- ! : .:z - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M