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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----.----- (Complete in Triplicate) Permit No:.__17-�_-_ - -------=----------------------------------------------- _______________ 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 i described. This'application is made in compliance with County Ordinance No. 549 and existing Mules and Regulations: JOB ADDRESS/LOCATION ---------1 -�--------- } l CENSUS TRACT -------------- ............ Owner's Name .________.___� r s p d -- Phone , 5` Address ------------------ '3 -------• Q f L1` " 'ta"-'L- ----------------. City Contractor's Name ---. / - - - -- -- --- - L ice nse #og'7.-/_77----- Phone Installation will serve: ResidenceI(Apartment House❑ Commercial:❑Trailer Court ',❑ Motel ❑ Other -------------------------------------------- Number of living units:____!_____. Number of bedrooms __.Z-----Garbage Grinder Lot Size __".2�__�1�,�__ .___ _ Water Supply: Public System and name ---- --------- J�9-------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ : Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe;r Fill Material ___________ If yes, type ___________________________ r� W {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,) i PACKAGE TREATMENT [ ] SEPTIC TANK[ je'* ie________________________________________________ Liquid Depth ----------- ............... r Capacity --------------------- Type -------------------- Material---------------------- No. Compartments ----------------- Distance to nearest: Well ___ ________________________________Foundation ----------------------- Prop. Line _____________________- LEACHING LINE No. of Lines ______` --- ---- Length of each line------ _�____._____ Total Length ---3�. .............. 'D' Boxt�;±<'csT�-R' pe Filter Material _/�_�_____Depth Filter Material --- . r. `�_________ Foundation __ ______ Distance to nearest: Well _____________ 1�-__.__________ Property Line_ ____�_._ ._____.._. [k - Depth __,l(1________ Diameter pr__,e��_O___ Number _______.__ _____________ Rock Filled Yes W No Ser -tf' Water Table Depth -------_ �------------------------------Rock Size ----- ---------------------- Distance to nearest: Well _ —_----------------------Foundation ----______________ Prop. Line __________..__._.___.. REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------_--------------------- Date __________________________________) Septic Tank (Specify Requirements) -------- ------- - T ----------------- --------------------- ;�`,---------------------------------------- ---------------- ---------------------------------------------- Disposal Field (Specify Requirements) -------- =------- ? ---------------------------- or P _______________________.____________-_.____._______._. (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 ---- BUILDING PERMIT ISSUED -- -------DATE ----- ---- ----------- ADDITIONAL COMMENTS -------------------------------------------------- ------------------------------- ------------------------------------------------------------------------ --------------------------------- ----- -----------------------------------I ---- --------------------------------------------------------------------- ------------- --- �nal Inspection by: -------=------------------------------------------------------------------------------------------------------------ FiDate __ �__ _ Y. SAN JOAQUIN LOCAL HEALTH DISTRICT E.- 9- -)-'68 Rev. 5M