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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 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 wit ounty Ordinance No. 549 and existing Rules and Regulations: r 1:L 3O-V Lv JOB ADDRESS%LOCATION ---17-- ----- =__...S�`" CENSUS TRACT __°` "------.. Owner's Name ------- - - ----------- -- ------------Pho a ----- - Address ----- --- C, 1 Ity � Contractor's Name _..- --- -- -s--- -- -------- License # _� - �1—__-- Phone ----------------------------- - Installation will serve: Residence ❑ artment House❑ Commerci ?: Trailer Court l0 Motel ❑ ther -- r'!_ -.` L- _S`7 a o Number of living units:------------ Number of bedroom _ _______Ga age Grind ------------ Lot Sizel_______________________________________ Water Supply: Public System and name ------------------------------------------------------------------------------- -------------- ----------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy_Loam d Clay Loam [] Hardpan 0 Adobe-E] 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.) l ` NEW INSTALLATION: (No septic tank or seepage pit permitted if 'public'sewer'is available within 200 feet,) LN PACKAGE TREATMENT ( ] SEPTIC TANKJJ Size__✓•-__ .. Liquid Depth ----------- ............... 0 Capacity dO jyPeMateria _ _-_-M- at- rial-(�- 4No. Compartments �------_:. -------- Distance t�nearest: Well ------- q - ----f--rl--Foundation ._. 4 _______!�_�_______ Prop. Line ____-�............. LEACHING LINENo. of Lines] � -----------. Length of .each-line---- Total Length ,------ " 'D' Box ----- ---- Type Filter Material --------S_s s.Depth Filter Material --------- .......:............. Distance to nearest: Well _____^s '________ Foundation ______ a_ ;: __P.roperty Line ___,_______:__�__ SE€Pk eT [Xj Depth ---_ r-- ------ r rX---rn_.�Number _ ---.-----�__________ Rock Filled Yes � No ❑ e i r. .. . �` f� Water Table Depth ------------------------------------------------Rock Size ----1-12 'Y �� e � Distance to, nearest: Well ____--_____!r_ _ ____________________Foundation ..__�p__________ Prop. Line ____:_��..._. I REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) - SepticTank (Specify Requirements) --------- ------------------------------------------------------------------------ ------------------ ----------..----------------•--•----_ DisposalField (Specify Requirements) ------------------------------•--------------------------------------------------------------------------------------•--------------- (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." I Signed -------------------------------------------- ' ------ Owner By - moo. ----------- '+• - Title -- - ----------------------------- (If other than owner)rr- t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __ ____ __ _____ ___ ___± _ �` ' -7-3 DATE __.. -------------------- BUILDING PERMIT ISSUED ----------- %-------------------------------- -------DATE - --- -------•----• ••-- --------- ------------------------------------- - -------- ADDITIONALCOMMENTS ------------=----------------------------------------------------•I------------------------------------------------------------- ----------•------------------- ------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------- -- ------- ----- --------------------------- ----------- Final Inspection b -------- � �- -----------.Date --- -'� -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M AA 0