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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 ADDRESS/LOCATION )j yam____ %f�rJ_�X2�'s -f�� -feNSUS TRACT --------------............ Owner's Name &.7 _l 'a�� - � Phone ------------------------------------ 1--6w'- �9 -' . Address 37� �. - -- - ------ ------------ Cityt�,�'_l0Va Contractor's Name __ _.1--_ /-_t�- / ___________________-_---_-----._._____.License �( VI Phone . 3_.__._.. Installation will serve: Residence fil Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other -------------------------------------------- Number of living units:----t------ 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 ❑ 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 ...................... Ll Distance to nearest: Well --- --------------- ---------------Fo dation --------___--_------- Prop. Line .--.---------_---_-- LEACHING LINE [ ] No. of Lines --------__--__-__--_- Length o each line-___ ____________________ Total Length ------.----..--............. D' Box --..__.____ Type Filter Material _ __________________D pth Filter Material --_-----_._..._____._______...._.--....---- Distance to nearest: Well __._.___________ _____ Foundati n _________.____________ Property Line _________.__.__.__._.:__ SEEPAGE PIT [ ] Depth --- ---------------- Diameter ----_- .--.-._. Numbe _____________._----__-__- Rock Filled Yes '❑ No 0 Water Table Depth - ------ ------------------_--- ock Size ---------------- Distance to nearest: Well ______________ ________________________ Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- ate -..-----.-.-------..-----.--------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------------------------------------- Dispo I I Field (Specify Requirements) ----------------------•-- - --- - - ------ - -- �----- ---=------------------------ ------ -- -------- - ----- (Draw existing a"� ------ � / �,�'�� ` rs � �� 'nd 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 __________ . Q ------------------ DATE x7--------- ` BUILDING PERMIT ISSUED --------- ---- DATE -------------------------------------- ADDITIONAL COMMENTS 1�---------------------------------------------------- ------------ ------------------------------------------------------------------------ ------- ---------------- --- ------------ --- ----- --- ------- - - ------------- --- ---- -- -----------------------------------------------------------------------•-------------------- -------------------------------- ---------------------------------------------------------------------------- ----------------------------- -------------------------------------------------------------------------------------- Final Inspection by: -------- = Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M