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FOR OFFICE USE: 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 ADDRESSAOCATION __......f _47M_ _9----If 73-7------S------�.L-I�.y7Q__RT-.CENSUS � TRACT Owner's Name0 — �_ � --------------- - Address _ -�� 17/X _(� 9L�t./--------------- City � � iv � ------------------------------------------ Contractor's Name _-- .. ..-_ ' _ ;/V----------------------------------------License Pfd __ Phone Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ---M-alle-_____12Q_. Number of living units:--- Number of bedrooms _-Z----Garbage Grinder ----------- Lot Size -cs_f 'k' --------------- Water Supply: Public System and name --------------------- -------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand's` Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ Adobe ❑ Fill Material ------ ----- If yes, type ---------------------------- (Plot plan, showing size of lot, location of system ielation to wells, buildings, etc. must be placed on reverse side.[ NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,] ice! PACKAGE TREATMENT { ] SEPTIC TANK[ Size-----------&_>56 _ 0---------- Liquid Depth __.� 2-- ---------- � /Not acity ._�__-_- Type _(?0-a-f Material__d t^_6-44 No. Compartments ___�_ .. ance to nearest: Well ------- -_�__ ----------------Foundation __!'_�__�________ Prop. Line __�5 11___________ LEACHING LINE of Lines -_._ ?-------------- Length of each � _____ Total Length _/ d 'D' Box __- ------- Type Filter Material -Depth Filter Material ---- -- ----------------------------------- Distance ----------------- ----------------Distance to nearest: Well --- C __-------- Foundation ---IA_1--------- Property Line __�_________________ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth --------------------------------------------_-Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------.._.-----------------) SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------- ---------------------------- DisposalField (Specify Requirements) ----------------------------_ -------------------------------------------------------------------------------------- --------------- --- -------- ------------------------------------------ ---- --------------------------------------------------------------------------------------------------------------- ----------------------------- .-- ---------- ------------------------- - ---------------------------- - ---------------------------------------------------------------- ---------------- --------- ----------- (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 --- -- 'Z C� �` Title --- ----- ------------------------------------------- ( other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------------------------------- ----------------------------------- DATE ---- - pll � BUILDING PERMIT ISSUED -- ---- ---- ----------------------- -------DATE --------------------------------------- - - ADDITIONAL COMMENTS .. - ------ --- - - - ------------------------------------------------------------------------ ------------------ ----------------- -- --- --- - --- - ------ --- -- -------------- -------------Date `� ----------- Final Inspection __ - ------- - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M