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_FPR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------- (Complete in Triplicate) Permit No. ___________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATIONZ/_ ------ 1 ST__ RU- -_11A0C.yr 1_9_______________CENSUS TRACT __________.___-___________ --------------- -------------------Phone --------------•----------- ------ Owner's Name ------- --�.� �' -- ----- /P�5-----------------------------------------�- Address . 3` I"1C�Yo City i7C/�' Contractor's Name ---�f ,(`_j-------,z ' %C----S,'p,---------------------License # /2`.-T'Tj--- Phone � c .��.-•- Installation will serve: Residence]Apartment House-E] Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units:---1------ Number of bedrooms _,,_3------Garbage Grinder 41.o----- Lot Size _________- Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -P' 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:W Size____ ------------ Liquid Depth ___,�_---------------- on Capacity�,7�`al __ Type/f�;ISl` MaterialG��/z�/ _No. Compartments - _______________ Distance to nearest: Well ---------------------Foundation _1Q'____________ Prop. Line _s .............. LEACHING LINE [)( No. of Lines ___0-_______________ Length of each line___�f�___-_____.___ Total Length __ .`i!P-r--__ 'D' Box « Type Filter Materialp /- _��i�_____De Depth Filter Material _/__�_ _______--------------------- __ Distance to nearest: Well ____s` ----------- Foundation _?_V------------------ Property Line -_-________-_.___ SEEPAGE PIT. [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No C] 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) ---------- ---------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- - - - - ------ ------- -- - - - - - - - ------------------------------------------------------- (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 perforW e work for which this permit is issued, I shall not employ any person in such manner as to become subjec o Wompensation laws of California." Signed --------- -------------------- Owner --------------------- By ----------------- --------------------------------- ---------------- Title ------------- -------------------------------- ------------------------------------------------- f other than owner) .01N 10 FOR DEPAKIOENT USE ONLY APPLICATION ACCEPTED BY -------------------------------- _ . -_-•--- ---��_-- -____-- -- -------------------- DATE --- ---------------------------- BUILDING PERMIT ISSUED --------------------------------------------------------- --------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS ------ - - ---- ------------------------ ------ -------------------------------------------------------------------------------------------------------- ---=---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------- - -- ------ Final Inspection by: --------------- --------------------- ---------------------------------------------Date �.` -- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M