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FOR OFFICE USE: , , � APPLICATION FOR SANITATION PERMIT --------- -------- ---- -- Permit No. (Complete in Triplicate) --- -------------------------- ------------------------------ -__----:- This Permit Expires 1 Year From Date Issued Date Issued - "f__70? ------------------------------------------------ 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 ---- 0----------------------------------CENSUS TRACT ------------- '90q'- ----------- JOB ADDRESS/LOCATION _. -__ _ _ _ _ _ S�J�_____�1P-: ,y Owner's Name P✓sf' -------------------- ----•------ -------------Phon�--o?�y~ � Address -- -_'3X1_X2--------- Q��L /-- -....e_�-------------------------•- City f 07_0_SL-�------------------------------------------ Contractor's Name . , �1---••---�r /�-�1-- ------------- --------------- License # j`' -3-- Phone ------ Installation will serve: Residence ® Apartment House ❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units: ------- Number of bedrooms ---�2-----Garbage Grinder//.0----- Lot Size ....167-6-- ___`___.._. Water Supply: Public System and name ------------------------------------------------------------------------------------------------- -------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ AdobeZ Fill Material ------------ If yes,type ---------------------------- (Plot ________________-________(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 f ] Size------------------------------------------------ Liquid Depth -------------- ----------- Capacity -------------------- Type -------------------- Material---- ----------------- No. Compartments ------------------•--- r� Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. line -------......:...-.--- W LEACHING LINE [ ] No. of Lines -----------_-------_---- Length of each line---------------------------- Total Length -------.--.-........._.._.__ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material .---.-------------------------.------.------ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. _--_______-_______-_-___ SEEPAGE PIT [ ] Depth -------------------- Diameter -__-________-__ Number ______________._.._._______ Rock Filled Yes E] No i❑ Water Table Depth ---- -------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line _._-_-.......... .--.-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------_-------_------------------_) SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- Disposal Field (Specify Requirements) ---i9 .3 ,�� f -------------------------------------------- ------------- ----------------------------------------- .--� - r- -�--- r ------------------ --------------------------------------------------------- - U haU�(Dra sed re wired d'tion o rev side) _ I � eby certify that I have prepared this application an t at t e work wil 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' o sati. laws of California." Signed -------------- ---------------------- --------------------------- Owner By ----------------------------------------- ---------- - ------------------------------------- Title ---------- ------ ----------- ------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- -------------. DATE J46_~-_„3_.------.-""--- G-.- BUILDINGPERMIT ISSUED ---------------------------------- ------------------------ -- --------------------------------DATE - --- ------------------------------------ ADDITIONALCOMMENTS ------------------------------------------------------------------•------------------------------------------------------------------------------------------- ___---------_____---------------- _--- --__�_-____ _________________________- -_ _______ _-________._______.__-___-------___-_--_.--__---- ___-- -_,_-A-_ _ _-_-__- ________________________________-- ___ _ _-___-_-__-_-____________------__---__-_-_____-____.-_________.__--__---___---_-___-_____-__ ____{______ ________ _ _ Final Inspection by: `Mrd---- Date ---`----�--J --'-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.