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FOR OFFICE USE: .6. y APPLICATION FOR SANITATION PERMIT ;(,)- c -�-��' 7U--- ------------•---�-�___.------------ (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued -- D 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 �/ / ----- �. -SQA CENSUS TRACT y Owner's Name e�W--------- ,�f' �--------------------•----------------- ---------------------Phcjhe ------ ------------------- -AddrAddress ess ------31-/-6. ---------- ------- -------------------------•- . City /1/V--c?�OS1~-------------------------•-----•---•-•----------- Contractor's Name ----------1!5__1,215�117r-------------- --------------License # 3 Phone Installation will serve: Residence Z Apartment House❑ Commercial ❑Trailer Court ;❑ Motel [] Other -------------------------------------------- Number of living units----/------- Number of bedrooms ---�2-----Garbage Grinder/yU_--_- 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 ------ ----------•---- 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 [] No i❑ Water Table Depth ----------------------------------•-------------Rock Size -------------------------------- Distance to nearest: Well ______________ --------- _--_-__-Foundation -------------------- Prop. Line .................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------•---••----------------1 SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- --------------------------------------------------------•-- Disposal Field (Specify Requirements) -_-f -_-� �- .....--_-----.5; ------------------ - ------------- --- - - -- -� � ' r haU,e(Dra s d re uired d tion o rev side) I eby certify that I have prepared this application a 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, 1 shall not employ any person in such manner as to become subject to Workman' o sat' laws of California." Signed --------- ---------- ---------------- --------------------------- Owner By ------------------------------ -------- - ------------------------------------------------- Title ----------------------------- ----------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - ---- ------ �-- _42--c-101f------------------------------------------ DATE _ -•------- BUILDING PERMIT ISSUED ------- ------------------------ --------------------------------------------------------------DATE -------------•---------- -- ADDITIONAL COMMENTS ------- --------------------------------------- --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- ------------- - --__ - ------------- - ------ --------------------- -- ----------------- ----------------------------------------------------------------------------------- ---- ------------------------------ --- --- -- -------- ------- Final Inspection b --- ------- -------- p Y� ----�`'-�---- - - --------- ------------- ---- -- ------- - -E.- ----------------------------Date ----------------�--------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M J