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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ ------ LAW ... to-:_341------ O 1 f�7-6g � 3a _ �Y (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: 4� JOB ADDRESS/LOCATION .. 6 �� ' -------//- - - - - --'---- --fi,�l�-� eiTi-P?-- ��/T�f-'CENSUS TRACT --------------------•----- Owner's Name ------------------ -----------:----------------- ----- -----Phone ------------------------------------ Address FBF � F City = Contractor's Name ---- fir..-.=1V41.0- -------------------------------------License #� - - Phone L Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court 0 Motel ❑ Other Number of living units----- Number of bedrooms ______Garbage Grinder FAQ--- Lot Size ------------------ Water ---------------- --Water Supply: Public System and name --------------------------------••--------------------------- ---------------•---•--------------•- -----------Private,K Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- (Plot ______________________ _-(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,) f ' ' Liquid Depth ------------- N PACKAGE TREATMENT [ ] SEPTIC TANK Size__ }� _X !____ T_-_..._ Capacity`,Z�_Q.-- Type1� Material-�&_&,r--- No. Compartments r5 Distance to nearest: Well _____ �--�_________________Foundation �______--- Prop. Line =j _ . ....._ �, LEACHING LINENo. of Lines __.__ ____ r [ -----_-__-- Length of each ]in -- - ------------- Total Length ----_----- D' Box _ Type Filter Material` Depth Filter Material _____________________________ Distance to nearest: Well --------- Foundation - -------------- Property Line ___--`•- SEEPAGE PIT Depth __��.___ Diameter ,�� Number �-.______.________ Rack Filled Yes, ` Na i❑ �• th / i Fr Water Table De ---- p -ids--+��- - ------------------=--------Rock Size -�-"- --- - ----------- Distance to nearest: Well _._`.Gp ___________________Foundation /fwd___--_- Prop. Line ....... � REPAIR/ADDITION(Prev. 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: "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 Workman's Compensation laws of California." Signed ----------- Owner a / - r :. BY - ------ Title n ------ ----------- ----------------------------- (1 er than owner lFOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------I--- ------------�------------------------- ----------------------------------. DATE -- BUILDING PERMIT ISSUED t DATE ADDITIONAL COMMENTS ____________________ _ _ ---•-------------------- - ---- ----------------- ' ------------------------- ------- k Final Inspection b------------------------------W _`_ _-___ _ Date �"_7 _� p Y° ------------------------------- -- --- ------- - -- ---- - -- - SAN JOAQUIN LOCAL HEALTH DISTRICT `f E. H. 9 1-'68 Rev. 5M. °'