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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -___-____ (Complete in Triplicate) p p --------------------------- ----------------------------- DateIssued ------------------------------------ -------------------- 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: �� ------- IL{� ____1��0 ----------------------------------------- __ ' ��- CENSUS TRACT __ -~ �_._. JOB ADDRESS/L CATION �-�_�f_ °_-- Oa �"L. � SIL ------ Owner's Name - --� -- - --------------------------------- ----- ---------- -----.Phone ---------------- ------------------- Address r---------`111'1------- ------ City A�K_*k4f_101/4------------------------------------------------ Contractor's Name t L�` f � �L- -------------------------------- --License #AY3,Vl -- PhonecS� / Installation will serve: Residence ® Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------- ---------------------------�lt Number of living units:_-__ Number of bedrooms Garbage Grinder ob-_-- Lot Size _- C` / J9` '---------------- Water Supply: Public System and name ------------------------------------------------------------------------------------------------------f--------Private R Character of soil to a depth of 3 feet: Sand-" Silt❑ Clay ❑ Peat❑l ++ Sandy Loam -❑ Clay Loam ❑ Hardpan ❑ - Adobe E] Fill Material __i_ _Q-- if yes,type -----------_TV------------- (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 pif permitted if public sewer is available within 200 feet,} ,PACKAGE'TREATMENT [ ] SEPTIC TANK'[,] ".1 /th iz __________________________________________ ____ Liquid Depth .______-__._-.___________ VJ Capacity ------------ Type ------ -- --- Material---------------------- o. Compartments ------------- ........ 00 Distance to nearest: Well _______ __ ___________________Foundation ----- _----__._______ Prop. Line ___.-__---.....______ p LEACHING LINE [ ] No. of Lines ------------------------ Lef each line----------------------- ---- Total Length -----------_-----.-..------- 'D' Box ------------ Type Filter Mat --------------------Depth Filter aterial ------------.--.----------------------------- Distance to nearest: Well __________ _______ Foundation ----____-___. ____---_ Property Line ______________-__-_-___ SEEPAGE PIT [ ] Depth _____-____________ Diameter _ ________ Number ___ _ _________ Rock Filled Yes ❑ No 0 Water Table Depth ---- Rock Size -- ----- Distance to nearest: Well ___________ _____________________Foundation __________________ Prop. Line _______---______._ __ -- REPAIR/ADDITION(Prev. Sanitation Permit# ________._____--_._ --------------_--_ Date ______-___ __-::______________-_--Septic Tank (Specify Requirements) ---------------------- ------ ----------------------- -------------------------- Dl�posctfField (Specify Requirements) ------------------------------------------- ----------------------------------------------------------------------------------------- - !' N------�' a-41-------��-�'------��- ------l��f��'F�jy----------��s�� ---- ------------------- --------------------------- ----------------------------------------- - - . ---- -------------------------- -------------------------------------------- -----�- (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 Wor an's Compensation laws of California." Signed _.6?�ell • Owner - ---------------------------- BY --------- ------------------------- - ---- --------- ----------=---------------- Title --------------------------------------------------- -- --------------------- (If other than owner) FOR DEPARTMENT USE ONLY ~pr"r+ =�1`- - ---------- APPLICATION ACCEPTED BY --------1---�-�1-`-�--'------------------------------------- --------------------------------- DATE ------ - - BUILDING PERMIT ISSUED ------------------------- - ------------------------------DATE ----------------------- -- ------------------------------------------- -- ------------------- ADDITIONAL COMMENTS -------------------------------------------------- -------------------------------- --- ---------- ------------------ --- ------ -------- -- --------------------------------------------------------------------------------------------------------- ----------------------- -------- ---- ---- ------------ - ------------------------------------------------------ ------ --------- Final Inspection - ---- ---- - ------ --------------------------.Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M