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i� R OFFICE USE: r -------------------- APPLICATION FOR SANITATION PERMIT ------- ------------------------------------------------------- (Complete in Triplicatel 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 permit to construct and install the work herein described_ This application is made in compliance with County Ordinance No. 549 and eisting Rules and Regulations: JOB ADDRESS/LOCATION Owner's Name f/ - V------Q��W-X'CENSUS TRACT ---s-- 7 --------------------------------------- ------- = Ph Address ----- (Ci- _�' .-- ------------------------------- ------- --------- city - - - - Phone Contractor, L y _ °�t - s Name --- -- -_�. •c,- -_- ------ = License #<_ - ---------- Phone ------------------------ fnstallation will serve: Residence 'Apartment House❑ Commercial:❑Trailer Court Motel p Other Number of living units.- �_----- Number of bedrooms _3 Grinder ------------ Lot Size Water Supply. Public System and name pp Y� GGA-z•..��-C';�,�----- - - . Character of soil to a depth of 3 feet: Sand ❑ Silt'❑ Cla Private Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe,[j 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,} W PACKAGE TREATMENT [ ] SEPTIC TANK W [ I Size----------------------------- ---------------•-- Liquid Depth --------------•-- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------•--------------- Distance to nearest: Well --------------- ----- -- ------Foundation ---_-------------.--- Prop. Line ------•---.------------ LEACHING LINE [ ] No. of Lines --_______- --_----__-_ Length of each line------------------------- . .— _ Total Length -------------------- "-- Box ------------ Type Filter Materia! _________________"_Depth Filter Material - Distance to nearest: Wel! ------------------------ Foundation __._-___--_ _____________ Property Line SEEPAGE PIT ----------•----•----,.._ [ ] Depth -------------------- Diameter ---------------- - ---- -------- ----- Rock Filled Yes ❑ No i❑ Water Table Depth --------------------- • ................Rock Size Distance to nearest: Well ________________________________________Foundation ----- ------ ------- Prop. Line ---••---------........ REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date Septic Tank (Specify Requirements) __---___-__ --------------------------------------- ----------------- ------------------- ,Field (Specify Requirements) D�s osa! y ---�. •- ------- �-vi (Draw existing and required addi on on reverse side) a € 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." Signed --------------- ------ --------- - --------- - ---- ------- Owner ---------- ------------------------ Y BY ------ ------- --- - �`y�---------------------- Title (If other than owner) ,FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __-_ ---------------------------------------------------------------". DATE --- - '7 BUILDING PERMIT ISSUED ---,--------------------- ------------ -------------------DATE -------------- - DDITIONAL COMMENTS --- --------- - ------- - ---------------- ------------ -------- -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ---------------------------------------- Final Inspection by: - ------------- ----------------------------- ------ --------- --------------gate ------ ------- - ----------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M