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FOR OFFICE USE: rt APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _'%�' .�. --------------------------- ------------------------------ This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATION ._L71.1Z c1 __ -------1 _�___C _ .__r� //1/Z� 1_'_CENSUS TRACT .____C�________________ Owner's Name / .!_-l2._ lJ- - l�/tl----------------------------------------------------M----- Phone Address /R .2 c� ----- V��1d� . City `--1- �! - Contractor's Name __- _� 'C? - ---------- ------- License # --0-- Phone �_ti -0.�j�- ... Installation will serve: Residence0partment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other _--_ ________________....- Number of living units:------------ Number of bedrooms _.-------Garbage Grinder NO____ Lot Size -..-___ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private 2 Character of soil to a depth of 3 feet: Sand f @ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material l_l 0-_-- 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 ___-__-_____--__ ----- U 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 -----------------..-.-_: 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) -------------------------- ---------------------------------------------------- ----------------------,----------------------------- Disposal Field (Specify Requirements) _______./.vQ _______�__C'�¢___C-/Z------ / -G--"-""'----�11�'}'��---------- t 11� rrr �a U S-�---------- 6 /V� - 1F--�rJnf_Al[_1�(tcf J4 8©x------------- ----- --------------------------------------- ---------- - - ---------- -- --- (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 SanJoaquin 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 t nth performance of the work for which this permit is issued, I shall not employ any person in such manner as to be su ct t rkman's pensation laws of California." Signed QQ�L ---------------------------------- Owner By -------------- ------------------- ----------------------------------- Title ----------------------------------------- ------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- R-nG----------------------------------------------------------------------------- DATE . .............. BUILDING PERMIT ISSUED --------------------------------------------------------------------------------------------- -------DATE ADDITIONALCOMMENTS --------------------------------- ---------------------------------------------------- ----------- ------- ------------------------ ----------------------------------- -- ---- ---------------- --- ---- -- ------------------------------------------------------------------------------------------------------------------------- -------------------------- - -- -------------- ------------------------------------------------------- ---- Finall - - ----- - -- - - - - ----- -- ---- -----------------------------------------------------.Date ---- --��-r-�-�- -------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M