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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------=----------------------------- --------------- Permit Na. (Complete in Triplicate) f� Date Issued __.S `�_� __.__4/________________________._ This Permit Expires 1 Year From Date issued Application is hereby made to the Son 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 .__ __2 __ .._____ _________TCJ_ I .._.__� ----------CENSUS TRACT -------------------------- • a ---------------------- ._/ Owner's Name 1'2F' f '!'✓ 1------------- --------------------------- Phone.----- - -y— Address ---� �Cs W----- f ---------- City __l__Lzo p� Contractor's Name _Q_4 =----.c__�` - - -1� 'Q-------------------------- ---License #�_V.��u--._- Phone _'3_ Installation will serve: 'Residence R1 Apartment House T] Commercial ❑Trailer Court 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❑ Clay Peat❑ Sandy Loam ❑ Clay 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r \ PACKAGE TREATMENT { ] SEPTIC TANK:[ ] Si/hh e_________ ____ ___ Liquid Depth ________________ ---------- ).t Capacity -------------------- Type ----- ------ M terial---------- ---------- No. Compartments ----------- °A Distance. to nearest: Well ----------------------- ------------Foundation ____._______-____.___ Prop. Line ___.-----------.______ Qp LEACHING LINE ( ] No. of Lines __ ________ Leof ach line______________ ___---_------ Total Length ,_________-___-_______-_-__ D' Box . Type Filter Ma -- -----------------Depth filter Material -----------------------------_--------____-- ._� ._ _ Distance"to nearest: Well --------- ------ Foundation _ __--._-____.._________ Property Line SEEPAGE PIT [ ] Depth ___________________ Diameter _______ Number ___ ._____.______.________ Rock Filled Yes ❑ No 0 Water Table Depth ------------------- ---------------------R k Size -------------------------------- Distance to nearest: Well _________ _____________________ oundation -------------------- Prop. Line _________-________--__ M REPAIR/ADDITION(Prev. Sanitation Permit�# ---------------------------------------- -- ate ----------------------------------1 SepticTank (Specify Requirements) --------------------------:------------------------------------------------------------------------------------ ---------------------------- DisposalField (Spe ify Requirements) ----------------------------------- ---------------------------- --- -------------------------------------------- Ph ? / �c/ ---- ----- c ?_ h -------------------- i: (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 -- - - --- ------ ---- " Owner ----- -----------{ BY ------- ---------�-- -- --- - --- -------------------------- Title ---------------- (If other than owner) FOR DEPARTMENT USE O Y APPLICATION ACCEPTED BY -------------------------------- - ------- --- DATE BUILDING PERMIT ISSUED -- --------- -------- ---DATE ADDITIONAL COMMENTS . - = --------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------- - Final Inspection by: ---- -------------------------------------------------------------- --------------------� --- -----------------------_---_---- ---2------------------------ P - -----------Date --- _c�: ------------------------ SAN JOAQUIN LOCAL HEALT DISTRICT E. H. 9 1-'68 Rev. 5M