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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ` ------- -- ---- -- -- �---------------- Permit No. ------------- -- -- (Complete in Triplicate) ____________________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 .� �FF .4 °' 04, ------------------ ---- CENSUS TRACT Owner's Name A -- -----------Phone -------------------------- - - - -- - --------------- . } w Address - J '� !L 1• �Cr_. Ci# --'----- - --------------"---------------- Y Contractor's Name ------ _ ----- ------------ -------license # __� _ ' ' Phone ----------- ---- " -------------- Installation will serve: Residence [�<jpartment House❑ Commercial ❑Trailer Court ❑ Motel ❑ Other -------------------------------------------- Number of living units:----t------- Number of bedrooms ;2""-.-_Garbage Grinder -_Io--- Lot Size --- _ E`'r'' _�__.________ Water Supply: Public System and name ----------------------•---------------------------------- --•---------------- -------------------------Private [ Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat �Sandy Loam ❑ Clay LoamF] Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type --------- ------------------ (Plot pian, 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,) \ 01 PACKAGE TREATMENT ✓ �_! [ � SEPTIC TANK'L�! Size" ��--�-g---�---- -" - - liquid Depth --V.------------------- Capacity ._-� a _- Type . __-__"-_.____ Material-__ No. Compartments ?r. Distance to neares . Well --f_______________Foundation -_- is Prop. Line ___�-------------- ` .41 LEACHING LINE [� No. of Lines ---------- Length of each line-------�--------------- Total Length ______________ (/1 'D' Box ___ -___ Type Filter Material ____ �R:______Depth Filfer Material --------/f_�-__________________________ Distance t nearest: Well --------�_'r5-0_01------ Foundation --------�---____-___ Property Line -______________ SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number __ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -----------__ ------------------- Distance to nearest: Well -----------------------------------------Foundation- ______________-_________________.____-Foundation,____.__._-____-___ Prop. Line -----_----_____.---___ A REPAIR/ADDITION(Prev. Sanitation Permit r# --------------------------------------------- Date _________-__.___-___--___--_____) f Septic Tank (Specify Requirements) ---------------------- -- ----------------------------------------------------------------•. ---------------------------- Disposal Fi Yd (Specify Requirements) equirements) ---------------- -------=------------------------- ------- _ f --- ----"--------------------- ----------------------------------------- -------------- ----------------- r - - - ------ - --- - --- --- -- (Draw existing and required addition on reverse side) t 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 s 10N, to Workman's Compensation laws of California." Signed ------- Owner BY �1n 14— DTitle /Q ' �'�" (If of er than owner) FOR DEP ENT USE ONLY APPLICATION ACCEPTED BY (-' -- -------------------------- ------- -------------------------------------------------- DATE ld ------------------ BUILDING PERMIT ISSUED -------------------------------------- --------- ------------------- ----------------------DATE -- -- - - ----------------------- ADDITIONALCOMMENTS ----- _ --- ---------------------------------------------------------------------------------------------------------------------------------------- --------- --- ----- ---------------------------------------------- -----------"- --------------------------------------------------- --------------------------------------------------------------------- -- ---- - ---:- -- ---------------- Final Inspectionby :. � Dafie -� �6- -------------------------------------------------------------------------------- " _� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M