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FOR OFFICE USE: -' APPLICATION FOR SANITATION PERMIT -------------------- V_0 - (Complete in Triplicate) Permit No. - -� _ K ----------- This Permit Expires 1 Year From Date Issued Date Issued _L: ...e_). / r J 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: ! JOB ADDRESS/LOCATION .� - _ _ _ _ , -------------------------CENSUS TRACT � Owner's Name _ -_ --------- p ry, - -- Phone 2/. Address - l /_ _.1� Clt -•--- Cit i ✓ ------ - ----- Y �—� - ----- --- ---- ----- - Contractor's Name - ,_,_, � = 40-------.License #�� - ,�/ Phone ------------------- Installation will serve: Residence impartment House-El Commercial:Trailer Court Motel E]Other ---------- ------ Number of living units:-.---/---- Number of bedrooms _3____-Garbage Grinder _------_-__ lot Size _____________ ____ ester Supply: Public System and name ___- _ ------•----- ------- \- - - ------------ - Character of soil to a depth of 3 feet: Sand'Q Silt 0Clay .� -------Private Peat❑ Sandy Loam Clay Loam .0 Hardpan E) Adobe 'E] Fill Material ------ ----- If yes, type ---------------------------- (Plot _____________________ _(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 �y [ 7 Size--------------------------------------------- Liquid Depth ---------- ----------- Capacity - ---------------•-- Type -------------------- Material------------------- - No. Compartments Distance to nearest: Well -------------------------------------- ' Foundation Prop. Line ---------- ----;--- LEACHING LINE [ ] No. of Lines ------------ !__w Length of each line' ._.4__________-_ -____.____-- 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 eWater 7able.Depth ----------- --------Rock Size Distance to nearest: Well -------------- -----------------------Foundation -------------------- Prop. Line -----------------• --• REPAIR/ADDITION(Prev. Sanitation Permit# ---_----.----------- ----- ----------- -- Date --------------"--_____-- _ Septic Tank (Specify Requirements) --------_------------------ ------------ ----- Disposal Field (Specify Requirements) ___�__-_- _- /�_ /� C ---(�' -----•-----�"7�-------------------------- 1 71 hereby.certify that I have prepared this application and 'thatch ---------- ---------- ------------------------------------------------------------------- I (Draw exist i g q dition on reverse side) y y e 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 ----- --- -- ................ Owner —�- ------------------ BY ----- --------- - ---- Title f other than owner) ___------ - -- - ---------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED -BY 'BUILING PERMIT ISSUED ---- -------- -- ------------------------- ------- DATE -- - ------------- AL COMMENTS .--- ---- - ------- - --- �-------------- ----- -------- ---------------------------------------------------------------------------------------------------------------------------------- ° --------------------------- - ------------ SAN ------ Final-inspection b - --------- ------------------------------------------------ ---------------------------------------------------------------------- �r - -�- -- -- ---- ---- --------- ------------ --------------- ------- --------- ------Date /._�,�..---:�--- � ---------- - SAN JOAQUIN LOCAL HEALTH DISTRICT i E• H. 9 1-'68 Rev. 5M - f