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f x FOR OFFICE.USE: ! APPLICATION FOR SANITATION PERMIT �d 3 z ..................................................._ - Permit No...7 .----........ �* r 3 (Complete in Triplicate) ............. .-._ .. 1---•- . // This Permit Expires t Year From Date issued Date Issued .// [ Application is hereby made to the San Joaquin Local'Heolth 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: /f / �.�........ .......................... JOB ADDRESS/LOCATI N ........__ rJ�c .. •................ .. .�. ..-..C .I/........ ._.. . CENSUS TRACT F �•+ .. ..... r ...............................•___• Owner's Name . .. .__..... ..................................... Phone __...... ••-- Cit ..._..................._......... ... ...... ---- Address .��- ,...�,-./--��-._...---- y J Contractor's Name - ... License #a2.7� ..3. Phone Installation will serve:) Residence partment House❑ Commercial❑Trailer Court C) ��a ' Motel []Other f / Number of living units:....(__-::_ ..Number of be*o— s _..._.i2 ....Garbage Grinder .L -AS. Lot Size ............. Water Supply: Public System and name --------- ------ ...LCA,' _........--------.........---..._._..................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay -feat❑ 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 sl 0.) NEW INSTALLATION:i. (No septic tank or seepage .pit .permitted If public sewer is available within 200,feet,l PACKAGE TREATMENT [ ] SEPTIC TANK I ] -. Size--------...................•.................... Liquid Depth ......................... Capacity ------ == Type ------------• ...... Material...................... No. Compartments ...................... Distance.to nearest: Well ....................................Foundation .................. Prop. Line ...................... LEACHING LINE [ ] No. of tines ................. --- Length of each line................._.......... Total Length .......... ................. f Q' Box I....._._... Type Filter'�Moterial ..........:..... Depth .Filter Material Distance)to nearest: Well ........................ Foundation ------.........:........ Property Line ........................ SEEPAGE PIT ( 1 Ddotli : - .---------_ Dicimeter ........--•----- Nwnibef -------------- Rock Filled Yes ❑ No �] E Water Table Depth ---------................------------------.....Rock Size ------------------------_--- Distance to -•---------------------_---Distanceto nearest: Well ........................................Foundation ..................... Prop. Line ...................... I REPAIR/ADDITION(Prev..Sanitation Permit# ...........:.-----------.-------- ........... Date ---------------................r._.I Septic Tank (Specify Requirements) � -••••-•••••• -- ••• ---- •••••- >r Disposal Field (Specify Requirements) /`.__ �...... . ' -•---- ------ --------------------------------- ............-..............-------------------------------------------- ........................ t ........... --------------------------- = - (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." > iSigned ---- ------------- ------ •------ ---------- ------- .... .;-------------------..- ---- Owner T By -- ---- - --- ----------- ---- -- ---.---------- •- -------- itle ... (If-0#h . th o�serl I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - -- ------- -- 4Z_-T - DATE ..1 �z. = BUILDING PERMIT ISSUED ------------------------------•------.. ..... ----- -- - --- - -----.-DATE - - --------------_--- ..-----_..... ADDITIONALCOMMENTS ------------------------------ .....-.." -------------------- ---------------------------•--- -----------------••-------- ----------•-- = _ -- ............._-- -....--•.............. ..._ ..:.._...... Final Inspection by: _.. :.------ --•--• --- - - mate . .. _.... - r Eli 13 2h 1-68 lleir. � SAN ;IQAQUlN LOCAL HEALTH DISTRICT e/7h 3Ma&-