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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -------------------------------------------------------- (Complete in Triplicate) Permit No. - -- --- ---- --------------------------------- Date Issued _._ . _17 ----------------- -:-_-----------.------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. his application is made �in compliance �with County Ordinance No. 549 aand existing Rules and Regulations: 14� JOB ADDRESSILOCA?F(� .___7 .`. --------C..G C.c- -y--- -A„--------------- ----------..CENSUS TRACT S`a- ---- ------ Owner's Name -=- ---- ---- ------� - - - - - - -----------------------------------------•---- ---------- -Phone - - --� -. 7f Address --- _Y4city �Z�Lc� Contractor's Name -----.License # - 5' f_ _ Phone Installation will serve: Residence VApartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number ------ ------------------------Number of living units:____{______ Number of bedrooms ----3----Garbage Grinder ____ ------ Lot Size ------ _______ ____________ Water Supply: Public System and name ---------------------- ------------------- ---------------------------------------------------------•---------PrivateK Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam' Hardpan ❑ Adobe ❑ Fili 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,} PACKAGE TREATMENT [ ] SEPTIC TANK ( 1 Size------------------------------------------------ Liquid .Depth --_-----------------_----- CapacitY Cy Type p _ Material_ No. Compartments ----- ____-----_ 4' Distance to nearest: Well --------fid_________________Foundation ------l.9---------- Prop. Line __,�___-__----__ LEACHING LINE [ ] No. of Lines ........ ------- Length of each line-------/__b-0----------- Total Length _______ .......... 'D' Box __`_ - Type Filter Material ---- —______Depth Filter Material ------9__1�_____________________•---__. Distance to nearest: Well _____vd� --------- Foundation ------/a----------- Property Line `'-_-__. SEEPAGE PIT [ ] Depth __a5' -- ---__--___ Diameter ?_ Number _.__--.-_ --____________ Rock Filled Yes No Water Table Depth --------- -�----------------------------Rock Size ----- -------------- Distance to nearest: Well _______________________Foundation Prop. Line ____._________:------- REPAIR/ADDITION(Prev. _---__REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------------•-} SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------- ---------------------------- Disposal Field (Specify Requirements) --------- --------------------------------------------------------------- R ------------------ - ---- --------------------------------------------------- ------- --------------------- (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 -j ---------------------- Owner BYAl-- . - --------------------------------------------------- Title ----------------------- ----- ------------------ (if other than own r) oa FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _-_ - __Ire-.. _ ----------------- DATE -____-___ BUILDING PERMIT ISSUED ------------------ --------------------------------------------------- ------------m--------------DATE ADDITIONALCOMMENTS --------------------------------- ----------------------------------------- -- ---------------------------------------------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ----- ------------------------------- _ �y ------------------------------------ --------------------------- ---- --- - - -- Final Inspection by: ------------------------------------------------------------•----------Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M