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FOR OFFICE USE. - APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. i ----------------- ----------------------- �-A ----------------- A- ------------------------------ This Permit Expires i 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations: [ JOB ADDRESS/LOCATION . Owner's Name ------ - - --_ ---- -- ---------------- .- --CENSUS TRACT ------------- I• -. - ___0 - - --•-------- ----------.--------- ----------------- ---------Phone ------------------------------------ { 7 �f ' Address . -------- -- -- -- ----- s�- ---------------------------------- city ----------------- --------------------- -------------- Contractor's Name - --- Phone ------------------- Installation will serve: Residence W9 Apartment House❑ Commercial ❑ ailer Court Motel ❑ Other ------------ -----------------------•------- Number of living units:------ Number of bedrooms ---r` .-_Garbage Grinder ------------ Lot Size 17-A......................... Water Supply; Public System and name ---------------------- --Private Character of soil to a depth of 3 feet: Sand' Silt i ❑ ❑_ Clay ❑ Peat❑ _ Sandy Loam❑, _C!aY.Loam 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.) N INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Jv NEW EATMENT [ ] SEPTIC TANK; Size�k10-_� '+� PACKAGE TREATMENT ----------------- ------------ Liquid Depth -�----------------.----- �l Capacity 1A_P*T------- Type ,rMateria!- -x-r -%--___- No. Com artments f . Distance to nearest: Well --- d---------------- _:__.aFoundation /_0_1------------- Prop. Line - -.------------ LEACHING -:----- -LEACHING LINE No. of Lines ---- ------------- -- Length of a ch' li a--- ' 9 f moo__-� ---- Total Length ------------ `D' Box -- Type Filter Material _ _----- '_Depth Filter Material --. � Distance to nearest: Well -------------- Foundation 4q Property Line --__.- SEEPAGE PIT Depth - ------ Diameter --_- __--- --_ Number - —---------------- Rock Filled Yes, ] No I❑ �] _�--� �•3'! ✓ Water Table Depth ------------------------------------hock Size --- ".�� ---------- Distance to nearest: Well/I--------------------------------Foundation ------------- Prop. Line _--r.__- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------------ ---------- Date --_------_.----_-_.._..__-____-.._} Septic Tank (Specify Requirements) -------- -------------------------------------------------------------------------- Disposal Field (Specify Requirements) -------------_-------_-_------------__----------_-__ ---------------- ------------------------------------------------------------------------------------------ -- t ..� _. --- - - -- raw 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 becorpe subject to Workman's Compensation laws of California." Signed - ------------ 'L- a------•-------- ----- Owner BY ----------------------------------------- ------------------------------------ ------------------------ Title ---------------- (If other than owner) = FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -----. DATE - d_� - ----__- -- . BUILDING PERMIT ISSUED ------------------------------------------- ---- --=--------------DATE _---- ADDITIONAL COMMENTS ---------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -------------------------------------------- -------------------------------------•--------..--...---- -------------------------------------- - - - - - - - - - - - Final Inspection by: _.--- - - ----------------------------------- Date -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M "!