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FOR OFFICE,USE: 3� APPLICATION FOR SANITATION PERMIT ra � ------- 10-2 2- �� Permit No. __ "- - ------------------- rn (Complete in Triplicate) - -��----- a� Date Issued _e 4MV-1. ----------------------------------------- ---------- This Permit Expires t 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 Ordinan a No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION � _ __,-___�______ / p ' CENSUS TRACT -----------____........... Owner's Name � _ d I le-ke-------- f -------------------------------Phone Address - -- -c'�~ ------- -----'4/_- , -------------------- City -51AM-----6 �/ Contractor's Name ------ __,_0,�..__;_____ _ _ ; -I�-______________________-License #al_(39-�l-_ Phone Y73_4S-- . Installation will serve: Residence �Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other --- ------------------------- Number of living units:___________ Number of bedrooms _______Garbage Grinder ___________ Lot Size - L-11 ........... Water Supply: Public System and name ---------------------------------------------------------------------------------------- ---------- -----------Private ❑ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat[:] Sandy Loam ❑ Clay Loam r[:]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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ______________-__,_-__- Capacity ------------------ Type ------------------- Material-------------------- No. Compartments ---------_---------- Distance to nearest: Well ___________________________________Foundation ____________________ Prop. Line ...................... LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------_____________________ 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -------------------------------- ........... Distance to nearest: Well _______________________ Foundation __________________ Property Line ...................e__-_ SEEPAGE PIT [ ] Depth ____ _ Diameter ________________ Number ---------------------------- Rock Filled Yes '❑ No iQ r Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ---.____-______________-________ -) Septic Tank (Specify Requirements) ___eep-wile_IM____ ______, oto/_.� /Y-_._____ c° L__________________-.•-- Disposal Field (Sp ocify Requirements) .!Y Z` �l/___..._f � _____' ______��_�__ ___ ----------------------- ------------------------------------------- --------------------------------------------------------------------------- (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 Wo an's Compensation I s of California." Signed Owner BY ---- . .. - - ----------------------------------------- Title - - - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --_-__________ _____ � G-� DATE -----------, ---------- -- ---------------- BUILDING PERMIT ISSUED -------------------------------------------------------------------------- ----------------------------DATE ------------- ----------------- ----------- ADDITIONALCOMMENTS ------ ------------------------------------------------------ ----------------- ---------------------------- ----------------------- ---------- ------------------------------------------------------------------------------------------- ------------- --------------------------------------------------------------------------- --------------- ----------------------------------------------- - FinalInspection by: -------------- -------'-'-`--------------------------------- ------------ -------------------------------Date --/1- f----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M