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FOR OFFICE USE: APPLICATION FOR SANITATION PERMITS ��9 (Complete in Triplicate) Permit No. ----------I---------------------------------------------- ---------------- @ Phis Permit Expires 1 Year From Date Issued Date Issued _s.: ------- Application 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 ! -- -- _CENSUS, TRACT __________________________ 14 Owner's Name = !Y�- --- Phone -L7_ _.�__./_J. . ------------------- Address --------------------- --------------- - `' ------------------------a City ----- ---------------- •-�- ---•---------- Contractor's Name _-------- ----- ....... ----------------------License #A04_sL/----- Phone A146-—A-0_ Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court ❑ p Motel E]Other --------- f / Number of living units:------/---- Number of bedrooms ----- ____Garba e Grinder ------------ Lot Size ----- ----------------- Water Supply: Public System and name ------------------------------------------- ----------------------------------------------------------------Private i Character of soil to a depth-of 3rfeet: Sand❑ Silt - Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam 1] Hardpan ❑ Adobe X 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,l i PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size-----------------------------------------------!t=_,,Liquid Depth,-------------------------- , Capacity ---- z_ ---------- Type -------------------- Material---------------------- No., compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation ----------1---------- Prop. Line ---------------------- i LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,-___-__--_--___--__-____•_- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----.----------------.-------------------_-_ ! Distance to nearest: Well ------------------------ Foundation ------------------------ Property"Line -------------------_---- SEEPAGE PIT Depth ____________________ Diameter ---------------- Number --------------------------- Rock filled Yes ❑ No i❑ Water Table Depth ___--------------------- -------------------Rock Size ______--------------------------- Distance _________-`_:F_Distance to nearest: Well,.___--------------------____ _ -•Foundation ----._____`___--__- Prop. Line __-____-__-----. -_-- � `!" ' - --------- REPAIR/ADDITION(Prev. Sanitation Permit# -_.-___,_________________.____..____________ Date ___-____--___-___-__-_-________-__) Septic Tank (Specify Requirements) --------=-------=---- d --------- -- Disposal Field (Specify Requirements) ------------ -------I ------TV (Draw existing and required ad4ition on reverse side) i I hereby certify that I have prepared this Lapplication and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Jbaquin.Local Health District. Home owner or [icon- sed agents cignature-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." w Signed --------------------------- -------- ---19--- - -- Own er -- - -------- -BY er} --- ------------------------ Title ------------ (if other FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY Q DATE r ----------------------- BUILDING PERMIT ISSUED ---- -------------------- ------------------------------ -----------------=-----------•--DATE ------------- ----•---------------- -- ------------- - - ADDITIONALCOMMENTS --------------------------------------------------------------------------------------- k ---------- ---- _ _ - ------------------------------------- --------------------------- -------------------------------- -- ------------- ------- SAN - ----- - ----------------------------------- Final Inspection by: ----------------------------------------Date _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M