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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT ------------------- - --- -- --------- (Complete in Triplicate) �. Permit No. Date'!ssued _q--------------- Application �4-71. - -------•------------------------------------------------- This Permit Expires 1 Year From Date Issued>' - k _ 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 ._._ _ f 1 � /71//ly la �I- + CENSUS TRACT r-a Owner's Name ----------------Phone Address ._- f -��--l---- t�-- ---------- - --------------------------- city _f G��1dw Contractor's Name _,_.__ _+__L: �--- -_---".License #v__y ' Phone _ Installation will serve: Residence Apartment House-E] Commercial:❑Trailer Court ❑ Motel ❑Other ' Number of living units_____________ Number of bedrooms ____________Garbage Grinder ___-____-___ Lot Size Wafter Supply: Public System and name _ --____S„I_ _ IP:�Q_ , �� c5'U /0/ "_ - private ❑ "T �� --- Character of soil to a depth of 3 feet: Sand To 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: I {No septic.tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK. ] Size___ _ Liquid Depth -------------------------- Ilk Capacity _ __-------------------- Capacity -------------------- Type ---------------- Material---------------------- .No Compartments - 4 Distance to nearest. Well ------------------- ---------------Foundation -------_- --- ------- Prop. Line -----_----_--- _ LEACHING LINE [ ] No. of Lines ________________________ Length o each line.________-----"______.___-_ Total Length "-_-._--- 'D' Box -_�________ Type Filter Material --------------------Depth Filter M terial ______________. . Distance to nearest: Well _______________ _______ Foundation _________________ _ __- Property Line _._____ SEEPAGE PIT [ ] Depth ----- ---- -----------•----- Diameter -___ -___ _-__ Number --------.------ ---- ------- Rock Filled Yes ❑ Na i❑ f Water Table Depth ------ - ---------- Rock Size --------- Distance to nearest: Well ------------ ---------------------------Foundation ------- Prop. Line .......... ------ I ------------ ---- REPAIR/ADDITION(Prev. Sanitation' Permit# __-_____.______-- ------------------------- Date _____ - _ -•----------•-------I I Septic Tank (Specify Requirements) _________ --- _ _ Disposal Field (Specify Requirements) ------- _ .__ __ .6v jZ -�*------------------- _... ------------------------------------ ------------------------------_--------------------------h 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 folilowing: "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 W rkman's`Compensation laws of California." Signed -- ---- I o -- - - - ------ ----------- -------- --- Owner By ------ title - -- --- - - ---------------------------- - -- - ---------------------=----------------------------------- {If other t an owny- USE ONLY APPLICATION ACCEPTED BY .. - DATE - =1 d -1�I BUILDING PERMIT ISSUED --- ----- -------- ------- ----------- - ------------ ------• ADDITIONAL COMMENTS ---- -- - �r _"DATE ----------------------- ----------------------- ---------------------------------------- -- ---- ----------------------------------------------------- --------------------Inspection by: __ - -----------------------------------------------------------------Date --�-- f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 7-'68 Rev. 5M