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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ---------------------- ------- --------------------- (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/LOCATION .-- , -y�-- ,-- t- ---- ,_---- '- - Q-j?------- p---------CENSUS TRACT __5_�-7--•----------- Owner's Name `' �- -s--------------------- ---- --------- --- --Phone ----- ---------------- . f Address -�_/ iz'� City - - ------------------ -- / Contractor's Name ___ _d_ _ _ _p }__ -I/_�}L/'/�___.5_,1=A,__.License # 46.l-. _� Phone -_!4_FJr__f ff5' Installation will serve: Residence% Apartment House,❑ Commercial :❑Trailer Court ;❑ I Motel ❑Other -------------------------------------------- Number of living units:--- Number of bedrooms -____..Garbage Grinder ___-A---- Lot Size .,?C3____ l�' �.................. Water Supply: Public System and name -------------------------- ------------------------------------------------------------- ----------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 'K Hardpan ❑ 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.) NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet) V PACKAGE TREATMENT f ] SEPTIC TANK f I Size------------------------------------------------ Liquid Depth ---------------------.----- Capacity --- ---------------- Type -------------------- Material---------------------- No„-Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---_---------_--.----- LEACHING LINENo, of Lines _._________.___________ Length of each line._________: f � g ------------ Total Length -----------•-- -------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---`-.--------------.------- ............... Distance to nearest: Well ________________________ Foundation Property Line ___________-__-____.--- `SEEPAGE PITDe th f 1 p ----------------- Diameter ------------ --- Number ------------------------- ockY:Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ---------- r�• -------------- Distance to nearest: Well ----------------------------------------Foundation ------1:_------------.- Prop. Line ---------------------- R EPAWADDITION{Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------__-----_} Septic Tank.(Specify Requirements) --------.-- -------- ---- --- -- Disposal,Field,'(Specify Requiremen 1 -- } -= r :. .- 4 Q ----- -------------------------------------------- (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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mannerF as to become subject to Workman's Compensation laws of California." Signed __ _ __ Owner BY Title *y ------------------------------ [If other than wnerl t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ----- --- ----- ------------------ DATE e� �--------------------- BUILDING PERMIT ISSUED ------------- -------------------DATE -------------------------------------- -- ---------------------------------------------------------------- ADDITIONAL COMMENTS - -------------------- ---- -------------•---------- --- --------------------------------------------------------- ------ ------------------------- -------------------------------- 10-11------- --------------------------------------------------- ----------------------------------- ------- Final-Inspection Iq:W --- ----------------------------------------•---------------------------------------Date '/ --±7J----------------------- i SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'68 Rev. 5M `