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FOR OFFICE USE: n� APPLICATION-FOR SANITATION PERMIT -- /� .+P� ------------------------------------------------ (Complete in Triplicate) Permit No: _` l.' --------- ----------------------------- 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 existing Rules and Regulations: JOB ADDRESS/LOCATION __✓ '_:_- --- -----:,� f� „-------------------------------------CENSUS TRACT --------------_--------- Owner's Name. ° '` gp • , @ — ' "��~ ----------------------- -------------------Phone-----------------------------•--•- n y Address ---- - city = Contractor's Name ------ r_� -- -- -__------- License # -�- _ '_ -_ Phone ------------------••---------- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------------------- Number of living units ----- Number of bedrooms .....Garbage Grinder ____________ Lot Size ---0--a, 4 Water Supply: Public System and name ---------------------------- --------------------------------------------------------------------------------Private f Character of soil to a depth-of 3 feet: Sand❑ Sjlt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ 4 Hardpan` 1 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.) E NEW INSTALLATION: (No septic tank or seepage pit permitted"if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size----------'--_ ------ --------------- A----- Liquid Depth ------------------- '% Capacity - --------------- --- Type - Material--------'�"_`_��~No. Compartments ------------------- Distance to nearest: Well/_____ ______________________________Foundation _____ -------------.Prop. Line ------------------------ LEACHING _______-- __.______LEACHING LINE [ ] No. of Lines ------------------- ____ Length of each line-----------------------------Total Length ____________________---_. `D' Box --------- i -- ,�,� _ Type Filter Material ---------------------Depth Filter Material --------------------.----------------------- Distance to nearest: Well ---------i-------------__ Foundation ---------------------- Property Line ------------------------- SEEPAGE ______..___.____.:.___SEEPAGE PIT ( ] Depth ____________________ Diameter 1'-______-___=Numb'er :_--_.___.-------- Rock Filled Yes ❑ No .0 Water. Table Depth ----- - ------Rock ize ---------=----- - 4 - -- ------ - ------------ 1+ ;.� 1 Distance to nearest: Well '---------------------------------------Foundation -------------------- Prop. Line -----_-------------- REPAIRfADDITION(Prev. Sanitation Permit# ----------------------------- _-=_- `'Date:;_ _ "'" " ------------ -1 4 SepticTank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- • `--.- :------------------- Disposal Field (Specify Requirements) __ __ #W ' rr --------------------------------------- ------ r v .-.�,.,, / -tea_ �-- - -- ------------------------------------------------- --- - ------ -------------------- j . r -------- ----- J-3----- ------ -------------------------------------- ----------------------------------------------------- (Draw existing and required addition on reverse side) -y.;,.�, 1 hereby certify that 1 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: r "1 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 . �- �.9 - BY ----------------------- -------- - � - --- �'��'��- Title --- �- ---------- -- - -------- (If other than owner) FOR .DEPARTMENT USE ,ONLY ol ,,,r..,..APPLICATION.-ACCEPTED-BY - = DATE ----------- BUILDING PERMIT ISSUED --------------------------- `---- -----�------------,-----'------ DATE ADDITIONAL COMMENTS--------- -------- --r---------------------•------ - _--_----------------------------- - :_. _----------- - ----------------------------------------------- ----------------------------------------------------- -- Final Inspection 6 ----Date ----- __ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M