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FOR OFFICE USE: It i APPLICATION- FOR SANITATION PERMIT ----------------------------- Permit No: (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued ------------ -- Application is hereby made to theSanfJoaquin Local Health District for a permit to construct and install the work, herein. described. This application is made in compliance with County Ordindnce No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . _. �__. Wp{_ " +4 -��~..___ ._ --CENSUS TRACT ------------------------------ Owner's ----------- -------------Owner's Name _f�+.3---------------=- .y 40,[_ ,:----= Phone ------------------- --- ----- Address ---------- .Zta I ` °� Q+� itY Contractor's Name -------- __ - .-------------------- License # _f fc _rPhone .-----------------_.--..._ .._ Installation will serve: Residence �artment House❑ Commercial :❑Trailer Court n Motel ❑Other `` Number of living units------- Number of bedrooms ___`Garbage Grinder ------------ Lot Size _______________________________________-___ Water Supply: Public System and name ----=--- -------------- - -------------------------------------- ----._.____Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt E] ------Clay ❑ Peat❑ Sandy Loam lay,Loam ❑ Hardpan ❑ Adobe '❑ Fill Material ----- ----- If yes, type ____________________________ - f Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT TIC TANK{ Size------------------------------------------------ Lq p Capacty - ---- Type ----------- Material---------------. .. No. Compartments nts _______________._ Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- _-------- Q 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 Water Table Depth ------- -------------------------------=--------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line -----------.____.___.. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_--------------------------------1 Septic Tank (Specify Requirements) -------- ------------------- -------------------------------------------------------------------- ----.. Disposal Field (Specify Requirements) _____ -___ ____ — _. _ _ ------- ----- - - -------- - - Et--B.@------------®-- " - •�_----- I`---- '� C 1 _`_1_.1-11i --------------------- ----- ------- ---------------- ------------ (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 Com pensati.o laws of California." Signed ------------------- ------------ 4 Owner - r By ---------------------------------- 6✓-' ---------- - Title - ------------------ - (if other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ---- - ------ DATE ---------------------------- - -? '--- --------------- BUILDING PERMIT ISSUED ----------------------- ------ ---------------------------------------------------DATE ADDITIONALCOMMENTS ------ --- - ------------------------------------ ------------------------------------------- --------------------- ----------------------------------------------- -------------------- ---------------------------------------------------------------------------------------------------------- -- ---------------------------------------- ------------------------------------- --------------------------- -------------------------------------------------------------------------- •------ Final Inspection by: _.-- -- _ - Date .�_. _-_7Z______________________ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M j