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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ --------------------------------•--- (Complete in Triplicate) 7� 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/LOCATION .:--------- --------- --------CENSUS TRACT ----- /------ Owner's Namel -------rn J?__,e'--------------------------- --------------------------------------------Pone ------------------------------------ Address ._.._.. ter /�rj') /�� = Ali - -13 Nd {iYc�i f . City 1�/ --------------------- t- Contractor's Name ----U'-A- ..___Oil_�_C°_L�`-P_______________________________License Phone Installation will serve: Residence ) Apartment House❑ Commercial ❑Trailer Court ',❑ o; Motel ❑Other -------------------------------------------- ,r Number of living units:--'-/.----- Number of bedrooms _ ------Garbage Grinder Lot Size _`-_ -------- Water Supply: Public System and name ------------ ------------------- ---------------------- Private Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ (Pl'ot 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 pi permitted if public sewer is available within 200 feet,) 6- PACKAGE PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ---------------------.-----oq; Capacity -------------------- Type ----------- ------ Material ------ No. Compartments ------ ------ --------- kn Distance to nearest: Well ___ ____- -----------------------eFo ndation ---------------------- Prop. Line .-_-___________,______ LEACHING LINE [ ] No. of Lines ________________________ Le gth` of each line ----------------- ------ Total Length ----------- ---------------- rn t ' 'D' Box ------------ Type60Filter M terial ---------------- --Depth Filter Material _____--______________________________.____-_ ' Distance to nearest-Q ell ___ _ _________________ Fou dation ------------------------ Property Line ---- ---------- SEEPAGE-PrT - ept iam er ---------------- umber -------------------------- Rock Filled Yes ❑ No ❑N %w V Water Table Depth ------- --------- -------------- --------------Rock Size -------------------------------- Distance to nearest: W _ __________________ _________ ________Foundation --------------------- Prop. Line ----------- ............ REPAIR/ DDITION(Prev. Sanitation Permit# _ ______________________ _______________ Date ---------------------------------- Septic -___---_________---_____________Septic Tank (Specify Requirements) Disposal y Fi Id (Specify Requirements) --------------------------•---------------------------- ---� ---- . -- - - -- - � ----- --- ------------- �9 ------ Gr-�_r,e -Q dr9 a ------------------------------------------------------------------------------------------------------------------------------------- --(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 k 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 Wor an's Compensation laws of California." Signed Owner ------------- By ----- Title ------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-F—{_C ------------------------------------------ -- -------- --------------- DATE r I l Y--- BUILDING PERMIT ISSUED -------------- -----------------------=--------------DATE -------------------------- ----------- ADDITIONALCOMMENTS ---------------------------------------------------------------------------------- -------------------- ------------------------------------------------------ ---------------------------- ------------------------------------- ----------------------------------------------------- -- -- --- -- - -- ------- -- -------- •- --- r� i L} Final Inspection:/ ';� '� 1 ----- --- '-------------------------------------Date ---------- Y - ------------ ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.