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FOR OFFICE USE: . - -%X APPLICATION FOR SANITATION PERMIT - ------ --------------- ---------------- ------- --- f � tQ '(Completein Triplicate) Permit No,W_-32-1 ------ This Permit Expires 1 Year From bate Issued Date Issued�-.17 7!;;--- 5 Application is hereby made to the San oaquin Local Health District for a permit to construct and install the work herein - described. This application is made 3 ianyp with Cou ty Ordinance`No. 549 and existing Rules and Regulations: f�tO T JOS ADDRESS/LOCA710N'7_�_- _6- e1 /Z / 1 -G. 4.... -. ----CENSUS TRACT �-- . Owner's Name 1��J!�f � al�. _ P =--------- --- ��1f '" !! ---- --Phone . Address L � 1f--l- lx _ City Contractor's Name _ `` �s•y , �•-^ t�_ /-e------------------------------------License Phone Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court i❑ i Motel ❑Other Number of livingunits------ 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 0 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 [ I SEPTIC TANK'[ ] Size------------- ----------- ---------- Liquid Depth -------------------------- oQ Capacity -------------------- T/ete -------- ---------- Mate -------------- No. Compartments Distance to nearest: W ______ ____________________ undat' n ---_--__..------------ Prop. Line ---------------------- W LEACHING LINE ( I No. of Lines _______________ Le gth of each ._..__- ---------_------ Total Length ._________________________ D' Box ..____-.__ Type Fterial _____________ ept Filter Material ________.____________________.______.______ Distance to nearest: We ._____---_-_-___ Founn _____________ Property Line _____-__-._______---___ (/) SEEPAGE PIT [ ] Depth -------------------- Dir -___--__________ Nu --_----._.._.._.__________ Rock FilledYes ❑ No 0 Water Table Depth ----- ----------------------------- ck Size -------------------------------- Distance to nearest: Wel ____________________________ undation --__..____________ Prop. Line ___.____.._.__........ REPAIR/ADDITION(Prev. Sanitation Permit�# _____ _____________________------ e __________________________________} SepticTank (Specify Requirements) ----------------------------------------------------------------------------------•-------------------------- -------------------------- (:�) Disposal Field (Specify Requirements) ----------------------------- -------- --------------------------------------------------- dh ------- -------- ��- -------- --- -- - ---------------0-AlIv ,�- i. V. - ----- �H ------------------------------------------------------------- -------------------------------------------------------------- (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 ONLY APPLICATION ACCEPTED BY - --- - DATE y --7 BUILDING PERMIT ISSUED -------------- --------------------------DATE ------------------------------------------- ADDITIONAtCOMMENTS ----- --------------------------------------------- ---�--- ---------------------------- ---------- ----- -- -- - - ------- ---------------- 011 -------- ---------------------- -- - ----------- ---------------------------- • -------- ----- - ------------------------------- f 2_ Final Inspects ------- ---------------------Data ---- SAN JOAQUIN LOCAL HEALTH DISTRI E. H. 9 1-'68 Rev. 5M