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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------- ------------- -----•------ -�_�_---9-6-I (Complete in:.Triplic6te) Permit No. This Permit Expires 1 Year from Date Issued Date Issued _10"Z0: 7 1. 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 Ordinanc No. 349 and existing Rules and Regulations: JOB ADDRESS/LO ATION _ _ - -: -- -- --- --- = -----------------CENSUS TRACT -------------- ------ r . Owner's Name - - - -------- - ----------Z----------------------------------------- ----------------------------- -----------------.-- ----- -_-Pe hone._�_ _ _-_0 - _7. - Address1��+° ------ ------- ---- -- ----- K/ City -t---- --- ----------------------------- 11 Contractor's Name ---- - -- -- -- ------- License # h _ Phone ------------------------------ Installationwill serve: Residence ["Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other -------------------------------------------- Number of living units:__._ __-__ Number of bedrooms __�_____Garba_ge Grinder -----------_ Lot Size _____-____________________________________ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: , Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam u Clay Loam 0 Hardpan ❑ Adobe ❑ Fill Material ,______ If yes,type ------______________________ (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ►r NEW INSTALLATION: {No septic tank or seepage pit permitted-if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK:(.v� Size _�._ f_ � W y � - �.--- - Liquid Depth ---- ---------------- Capacity YPe � Material-- __--- No. Compartments --- _- _-•-• .-•-- Distance to nearest: Well ________Sa----------------------Foundation ------kA--*-------- Prop. Line __ _�____________ LEACHING LINE No. of Lines ___.______ Total Length [ off. - Length of each line--------9d--- ----k4v a_....••-•••--•- 'D' Box ..-T :---. Type Filter Material ____S_ ________Depth Filter Material ------ ________________________ � w Distance to nearest: Well--------SQ........... Foundation --------�_Q_0-------- Property Line. ---...- ------._.-.--- SEEPAGE PITDe th -------------------- Diameter ____________-__ Number - ___________________ Rock Filled Yes C] No C][ 1 p Water Table Depth ------------------------------ -----------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...--------.-------_._ I REPAIR/ADDITION(Prev. Sanitation Permit# --------- ---------------------------------- Date ------------------------- -------- Septic -______Se tic Tank (Specify Requirements) ------------------------------------------------------------------: ------------- ,.---------------------------- Disposal Field {Specify Requirements) -------------------------------•------------------------------------------------------------ ----------------------- --------------- ----------------------- ---- ----------------------------------------------------------=--------------------------------------------------------------------------- -------------------------------------- (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,,l shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- --------------------- ------------- Owner BY ---------- - ------ ------------------ -------- � + _ __ Title --------- ..-------- (If other than-owner) - FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ----- - ------------------ -----• ---------- - � DATE J-a BUILDING PERMIT ISSUED ------------------------------------------------------ -------DATE ----------------------- h ADDITIONAL COMMENTS ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - — ----- -----------------------�-------------------------------------------------------------------------------------- --- - FinalInspection by: - - ------------- --- ------------- -- :.-----------------------------•--------------- -----------------------.Date -------------------------------- SAN ----ff-----" ----SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M, - . i