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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ---- - ------------ ------- --------- ------- (Complete in Triplicate) G � d 7J T ./-----"".-.-- .. This Permit Expires 1 Year From bate 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI / - -----`� W ------------ -CENSUS TRACT -------------- ----------- ----- �_ Pone ----------------------------- Owner s Name ----- f --------------- --------------------------------------- -----------------"------------------ ----:- --- - Address --- - s9L_Y__.__ ------------------------------------------ �L - --------- City` Y Contractor's Name - ---------------------License # j ' Phone. -------------------------------- - - - Installation will serve: Residence DWartment House,,❑_Commercial,:❑Trailer Court ,,❑ Motel ❑ Other ------------------------------------------ Garba ------------------------------ Number of-living units_____________ Number of bedrooms _ ____ ,ge Grinder --_______-_ Lot Size ------------------------------------------ Private._ b Water Supply: Public System,and name ---------------------}_ --------------------------------- ---•-•---_--- - _Private [ -� Character of soil to a depth of 3 feet: Sand'' Silt-F] Clay ❑ `'Peat❑ �5andy toflm �Clay loam ❑ Hard an Adobe Fill Material f.f___i------ if yes, type _-------------------------- p ❑ •. (Piot 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 it permitted if public sewer is available withirij200 feet,) } PACKAGE TREATMENT [ } SEPTIC TANK [ ] Size------------------------------------"------ Liquid Depth .-------------------,----- Capacity Type -------------------- Material-------------- ------ No. Compartments - ............... . Distance #o„nearesfi: Vllell T-___'__-'�___="__----::--`'"--Foundation--�-.___�-_-__-__--- Prop. Line ______________________ i 0 L. Ird LEACHING LINE :[ ] No. of Lines ___-____ __.-----"""_-- Length of each line____________________________ Total Length __- __..-.----------"_"_ D' Box --- ----- Type Filter Material --------------------Depth Filter Material --------.-----` ------ -------------- t Distance to nearest:'Well ------------------------ Foundation ,------------------------ Property .Line, ------------------- SEEPAGE PET [ ] Dep#h ______ _______ ____ Diameter _-�___--- Number ' '_ _.�_- ----°'-:-- Rock Filled' Yes 0 No.(] t— — Water Table Depth," t. =---------------- i----------Rock Size ----------------------•--- Distance to nearest: Well --________________ Foundation -.------------------ Prop. Line "-.-______--____.-..__ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------..-----------------) a Septic Tank (Specify Requirements) ----- ----- ----------•--------- 07 ---------Disposal Field (Specify Requirements)- __ ------------ - _ __ -"""_-- � t ------ --- - - � - ----------------------------- --------------------------------- ---- r (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- , ollowing: "1 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 becomes ject to Workman's ompensation laws of California." ' Signed ------------------------------ Owner f Title -------------------------------- -------------- ----------- ------ BY -- --- ------------------------ ------------------------- - (If other than owner) /L,j„ --FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- -- --- -F—''-4 -- ------------------------------------- ------------------ DATE --------------- ADD]TBUILDING PERMIT ISSUED ---------------------.--- ---- - ------------------------------ --- DATE EONAL COMMENTS ----- ----- -------- ------------------------------ ------ ------------ --------------------------- ------------ --------------------- ---------------------------------------------- ---- ------------------------------------------------- -------------------------------------------------------=---------------------------------------- = -----"- ---- -- -- E ---------------------------------------------- -------------- - ----------•------ Final Inspection b ------ sr c�- Date "_. - SAN'JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.