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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------------------- �a~`��® (Complete in Triplicate) --- ,; 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 existing Rules and Regulations: JOB ADDRESS/LOCAT ON .- 9_70_Y_ -------------------------- ---CENSUS TRACT --------------•----------- Owner's Name . - -��t Phone -------- ------ - --- ----------- ----- --- Address -J -- - --- j -------------------------- ------------ --��3--s- - ---= -- - - - --�- ,--� �.�--�. _ __. city -- --- --------- �--- Contractor's Name --------------- -- `- - - ----- ----- -11��- -- °--- ---.License # / �-�1-(---- Phone --- ---- ... will serve: ResidenceyApartment House❑ Commercial [Trailer Court !❑ ■ ^ Motel ❑ Other.---------------------------------------------- > __ ----- R _ _ _ _ Numberof'liv ni g units:___.________Numb r of bedrooms ________Garbage Grind Lot Size -= t l_'X- - ------------- Water Supply: Public System and name ------------- --------------------------------------------- �e� ------------------.... I_Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ ` Sandy Loam E]", ..Clay Loam_❑ Hardpan ❑ AdobeFill Material __1_i"_!____ If ye_s,type --_-______.________________ =` (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., must be placed on reverse side.j NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q j PACKAGE TREATMENT [ I SEPTIC TANK',' .�Sjize_________ __x_�______-_._- ____ Liquid Depth �______________ Capacity/�_blu.-------- Type ------- Materia[ aye—,---.--- No. Compartments ____7--_-----__ ' Distance to nearest: Well -----------—---------_______ P----___-- Prop. Line __ � ___Foundation __�_�'�___ ._ F -------- LEACHING-LINE--^��—No: of Lines _____________________ __ _'Len gth of each line---.------------------- ____ Total Length :�-��._____--------i I /� f� D' Box __!l_.,Ty.pe_Fllter Material ____ L-_____Depth Filter Material -___-��---_-----------------------( Distance to nearest: Well -------r----_________ Foundation ___.�_Q--f'________ Property Line SEEPAGE PIT Depth __.7.sS�_______ Diameter 5-3_.�_ _ Number -�-el Rock Filled Yes ' No IWater Table Depth -------------------"-------`-----`- --------Rock Size _L_��. X _�1�--- --. Distance to nearest: Well ___ _ _ _*_____{________-_Foundation _.1_�_�_t___ Prop. Line _______________REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date _------------------.---.----------Septic Tank (Specify Requirements) ---- - --------------------------------------------------------------------------------------:- ------ •-------------------------Disposal Field (Specify Requirements) --------------------------------- ------------------------------------ -------------- ------------------------------- ------------ --------------------------------------------- --------------------- -------------------- ---------------- ---------------------------•------------------------------------------------------------- (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: 4 ,, "I certify that in tht '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'C'olifornia." Signed ..-_----------------------- ------------ ---- ------ ------------------------------------ Owner ---------------------------- By ---------- ----- -- - --=------ ---r------ --- - --------------------------- Title ---- --- '------ {lf other an owner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---•-------------------------------------------------------------- DATE A0_-./�_ -�T----- ----------- BUILDINGPERMIT ISSUED -- ------------------------------------------------------------ ---- ----------------------DATE ------- ----------------------------------- ADDITIONALCOMMENTS ------- ------------------------------------------------------ -------------------------------------------------------------------------------------------- -------------------------- --------------- ----------------- ----- ----------------------- r ------------------------- ----- --------- -- ------------ -------- -- ----- --------------------------------- -----------------------/+ Final Inspection by: --------------------------------Date -- ---'-�------Y -- ----- -- - - - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M