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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. --------------- --- ------------- -------------------=• (Complete in Triplicate) q Date Issued I This Permit Expires 1 Year From 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: I t, --- - ---------CENSUS TRACT -- JOB ADDRESS/LOCATION . '' --- `- Phone6�f_'.6, -� Owners Name ----- --------,---""` "--- t --------- ----- - --- 0� Z31 y�,._. city ----- -------- - - -- ---------------- ---------------- Address - ------------------- '�''�';'--•-- - t h., L�d ------ hone W_6_-��_* 7.-- Contractor's Name ______---- ;._._____ Licen e # _--._._�_-_ _ Installation will serve: Residence XApartment House❑ Commercial : r Motel ❑ Other -------------------- ' ` c Number of living units------ Number of bedrooms _______Garbage Grinder Lot Size __ ---Z-6---------------------------- Water Supply: Public System and name ---------------- - ----------------------------- Private Character of soil to a depth of 3 feet: Sand❑ Silt ElClay ElPeat ❑) Sandy Loam Clay Loam { y� Hardpan ❑ Adobe❑ Fill Material --- --:if yes, - -- - - ,. -�type --`----------------- - - � e, • mer +�, : { Y p (Plot plan, showing size of lot, location of system in relation buildings-;-.,to'wells, buildin ,etc. ,must be laced on reverse side.) - — seepage pit permitted if public sewers available within 200 feet,) Q NEW INSTALLATION: (No septic tank or � � i PACKAGE TREATMENT { ]'° SEPTIC TANK'[ ] Size----------------------------------------' ---- Liquid Depth -------------------------- Capacity ( Ca -- T -Haiti""vial--------------`--- No. Compartments -------••------ pY ------------ -- Type ----------------- Distance to nearest: Well _ ._ - __-- - ' Foundation ---------------------- Prdp;L - Line --------------- ---•-- - _ LEACHING LINE { ] No. of Lines ----------------- ------ Length of each line-_-- �.----- �- -Total-Length _-----------.----...----- r +�s =---------•------•----•-- 'D' Box _____-w_ -- Type Filter .Material .--_---_---- -:`-=-48--Depth Filter Material---'--.-_:--_- ' �_ Foundation ----.+ ---------------- Property�,� e _ Distance`to nearest: Well ;; SEEPAGE PITC [ ] j Depth - ---------�-� Diameter ____--___------ Number ----------------- ------ Rock Filled Yes ❑ No ❑ r? f 1 + ti ` 1. ----_RockSize ------------------------- ------ Water Table Depth r I Distance to nearest: Well ---------------------------------------•Foundation ----;--------------- Prop. Line _-------------_------ it# -------- ----- � "�-- Date �--------------------------------) REPAIR/ADDITION(Prev. Sanitation Permit# ______-_s--------------------�---_-_--- V ; Tank (Specify Requirements) --------------------------------------+ ------------_-"_____ r --------- Septic ' - ----------------------- Disposal Field (Specify .Requirements) ---------- � --- --------------t Ie --------------------------------- t r • f i ! ------ --------- -- -------------------------------------------------- 0 ----------------- ---------------- --------------------- `------ ------=---- ------------------------------------------- --------------------- ----------------------------------- t -,� (Dravy,existindand required addition on reverse side) I Thereby certify that I have prepared this%application and that the work will be done in accordance with San Joaquin County Ordinances, State'Caws,'and'Rules'and'Regulotions of the San Joaquin Local Health District. Nome 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 steall not employ any person in such manner as to become subject to Workman's Compensation laws of_Californid." r Si ned - ----- ---------------- --------------------------------- Owner -------- -. - By If other r _ Title - y ------- ------ - ( owner) c _ FOR DEPARTMENT USE ONLY ACCEPTED BY - = $_� ------------ APPLICATION DATE BUILDING PERMIT ISSUED --------------------------- DATE ADDITIONAL COMMENTS ------------------------ - f --------------- --------------------� -------= --------------------------------------- - ------- •--- - - ------- ---- Final InsP ecfion by ..Date __ -- ------------ - -- ' SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1-'68 Rev. 5M'