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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 Cwl0rdinance No. 549 and existingul s- and Regulations: , JOB ADDRESS/LOCATION .- -�`--/�'-�- f� L1 E°'y"'` E US TRACT `�`fr ..------- - �f - Owner's Name --` {1� -- ----- ------------•--• ---------Phone.'3 l� 0 ' ---------------- Address ------ --------------------------------------------------- City ---------------------------------------------- Contractor's ----------------------- - - Contractor's Name -- ---------- ------------- ---------------------- ------License # ------.--:-------------- Phone Installation will serve: Residence [P Apartment House-[] Commercial ❑Trailer Court Motel ❑ Other '• Number of living units:___�____ Number of bedrooms -_______Garbage Grinder __ Lot Size _ ov. --- -------------------- Water Supply: Public System and name ---------------------------__ -----------------Private Character of soil to a depth of 3 feet: Sand'Q Silt❑ Clay ❑ Peat❑ Sandy Loam .0? Clay Loam.❑ A--c HardpanZ 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,) PACKAGE TREATMENT [ ] SEPTIC TANK ] Size__ f� "_ -_.________ Liquid Depth ._/1�� _------------ Ca pa city lrpP-------- Type __r�- -- Material_ _-- No. Compartments �_..-___- Distance to nearest: Well ----IS7b-------------------------Foundation .lo_____________ Prop. Line LEACHING LINE Nv. of Lines -A------------------ Length of each line------ ----- Total Length ----------------- ,Jf n 'D' Box -_ _-___ Type Filter Material ��__________Depth Filter Material __�_�_'_____________ _................ Distance to nearest: Well _�_v__ __________ Foundation _ s------------- Property Line �_FJ___. -__-_._-___ SEEPAGE PIT Depth "- __--- Diameter 71----------- Number --�-------------------------- Rock Filled Yes No ,0 Water Table Depth --- --------- ---•- --------------- � ___Rock Size _`�•`� � Distance to nearest: Well _��---------------------------Foundation -��---,__-- Prop. Line -----_-----_-.- REPAIR/ADDITION[Prev. Sanitation Permit# ---------------------------------- ------ Date -_-_--____________-____________--_} Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- Disposal Field (Specify Requirements) -----------------------------------------------------•---------------------- _-- --------------------------------------- ---- --- - --------- --------------------------------------------------------------------- ----- - [Dr(w 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 lice agents signature certifies the following: "I certify that in the performance of the work for which this permit i,s, issued, I shall not employ any person. in such manner as to be co a subject to Work an's C ensatiion laws of Californiirl, Signed Owner By ------ --- ----------------------------- ------- --------- -------------------- ---------------------- -� tr)� -- ---------------- ----------------/ENT Title [If other than own 10, FOR DEPARTSE + ONLY .� APPLICATION ACCEPTED BY - --------------- - - ----_. DATE - -- - --•-----.-- BUILDING PERMIT ISSUED DATE -------------------------------------------------------------------------------------------ADDITIONAL COMMENTS _____________ ______ �- ---- -- -- - -- c� _ � a `� L'----------- ---------------------------------------------------- - - --- - -------------------------------- ------------------------------ ----- -1 Final Inspection by: - -_- -- - _-----------.Date - ----- `- a---: SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M