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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - --------- ----- 3---- - ----------------------- (Complete in-Triplicate) Permit No. --------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _tea_-- -D-`7l- 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: 77 JOB ADDRESS/LOCATION .----�--/-I---�.�'----- --_-46, -�--------SS�------��C"r�-.4�-- -..CENSUS TRACT ----------- ----------- B n Owner's Name --------------- 07'-------------- -------------------------------------------- -------PhoneOS-�- Q � = ��/ .' - City ----------------------------------------- Address ----- Contractor's Name ..../110{ _t;---_ ,j„ j _---- ------------------License #� -� PhonetYy-'" Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑Other r � Number of living units:.--,/----- Number of bedrooms -____Garbage Grinder Lot Size __1 ---Ir---lIP ---- ________ Water Supply: Public System and name -------------------------------------------------------- -----------------------------------------------------Private..' { Character of soil to a depth of 3 feet: Sand Silt F] Clay E] Peat[ISandy Loam -F] Clay Loam [D ` Hardpan ❑ Adobe E], Fill Ma _ terial __.__.____-- If yes,type ____ ---------------------` * t (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'[ ] Size------------------------------------------------ Liquid Depth _______________________- V Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- V Distance to nearest: Well ------___________________________Foundation ---------------------- Prop. Line ____________-_. __.... LEACHING LINE [ ] No. of Lines _________________5 Length of each line --------------------------- Total Length ' YP --------------------Depth Filter Material ------------------------------------ 'D' Box .._____.__._ T e Filter Material -_---___ � I Distance to nearest: Well ------------------------- Foundation ------------------------ Property Line "�----------------------- SEEPAGE ___--_-____ _._._.__SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------- ------ Rock Filled Yes ❑ No i❑ Water Table Depth --------- --------------------------------------Rock Size -------------------------------- Distance ----- -------------------------Distance to nearest: Well _______________________________________Foundation --------------- ---- Prop. Line .--------------------- REPAIR/ADDITION(Prev. Sanitation Permit 5# ------------------------------------- ------ Date ----_-----------------------------) Septic Tank {Specify Requirements) ----------------------------------------------------- -----------------------------------------------------..--...---- Disposal Field (Specify Requirements) ---r� t _c�C ------ ---_-----_- Q' a --- - cS I�11�1 P ------------------------------------------------------------------------------------------------------------------------ � --------- ---- ----------------------- - --------------- (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: E "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner 7 as to become ZsubjectWorkma 's Com ensati.on laws of California."Signed --- ------ ------ --- - ------- - --------------------------- OwnerBY ---------- ----- -- ------ -- -- ----------------------------------------- Title - ------------- -- -------------------- (If oth r a owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- o6" DATE --- ----- ------ ---- -----------. BUILDING PERMIT ISSUED ._____.________________ �^ 1 --------------------- - ------------------- ------------ ---------DATE ------------------------------------------- ADDITIONAL COMMENTS . - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------L------------------------ ---------------------------- -------------------------------------------------------------------------------------------------------------------------- --------- - -------------------------------------------- -- - Final Inspection by: - -- ------------------- ----------- - ---------------------------Date 3 Y/ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M