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k FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 0 - - - -------------------- -------------------------- Permit Na: �-�=-----r-� (Complete in Triplieate) t """� --------=----------------------------------------------- ---------------------------- This Permit Expires 1 Year From Date Issued Date Issued --- Application -- Z o:-7 r A lication is hereby made to the San Joaquin Local Health District for pp y q 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: -' si JOB ADDRESS/LOC TION --------- ----- - -- --: ----CENSUS TRACT -- Owner's Name -------------------------------- -------- -----Phone -' _,_1- -'`��^ �. r f 4 f r Address --- City Contractor's Name --- _-I_ hr_Z --.rkP --- Phone- - _ - 'j°1 Installation will serve: Residence Pa Apartment House❑ Commercial:❑Trailer Court ❑ f Motel ❑ Other -------------------------------------------- Number of living units;----/----- Number of bedrooms --..-----Garbage Grinder Ares__ Lot Size Water Supply: Public System and name ---------------------- -------•----------------------------------------•---------------------------------------Private 1I Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay '❑ Peat❑ Sandy Loam 7k, 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,) 1,J PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size--------------------------------------- Liquid Depth -------------------------- Capacity ----_--._-_----__-- --_.Capacity ------------------- Type -------------------- Material------------------- -- No. Compartments -----------------:---- jDistance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------_--._.--- �4 LEACHING LINE [ ] No. of Lines ------------ ---------- Length of each line---------------------------- Total i Length 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --*---------------------------------.-:---- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line --------._---._-.-.:._-_ SEEPAGE PIT [ ) Depth ____________________ Diameter ---------------- Number ----------_----------------- Rack Filled Yes ❑ No i❑ Water Table Depth. •-----------------Rock Size ------------------------------- P Distance to nearest:-Well ----------------------------------------Foundation -------------------- Prop. Line ...................... T REPAIR-ADDITION(Prev. Sanitation Permit # ---_•- Date -- ---------- --- ------------�} Septic Tank (Specify Requirements) ------- 0 4.- -. -- -- --__- -_ - ____ I Disposal,E' I (Specify Re uirements) - ' �4 --------------------------------------- = _ ---------------------- ------------- -------------------------------------------------------------- f i (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 11 as to become subject to Workman's.Compensation laws of,California." t Signed --------------------------------------------------------------------------- Owner f BY •Q.�J------ - --- ---.-- Title ---- �------- ------------------------------ ------------ ------------------- (If other than caner); I FOR DEPAftTMENT�sUSE ONLY APPLICATION ACCEPTED BY ------ ------ --------------------- -------------------------- DATE .f:°Z w/0--)/------------------- , BUILDING PERMIT ISSUED - --- ----DATE ------------------------------------------- ADDITIONAL COMMENTS --- ----------�- _ /�- �4 ------------ - ---- ---- 7�------------------------ ---------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------- --- --- ---- ------ - Final Inspection by: ---- Date '" - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M