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FOR OFFICE USE: V 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 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 ` %-►-rte 1'----------------------------CENSUS TRACT --------------...--------- F__ _- .___ _�. E Owner's Na G' iLf = Z:!�2 ---------------------------- ------- 1, �' City ---�1`JF Address ----j] - -- /------ -------- ----- Contractor'shame '-k,�C" --11'0�1�_ r _-.License # 1�- ; Phone Installation will serve: Residence E] Apartment House[] Commercial ❑Trailer Court l❑ Motel ❑Other -------- --- - ------- --- --__-__.-.- Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------------------------------- Water -__---______-__- ____________--.--________Water Supply: Public System and name ------------------------------------------------------------------------ -------------- ------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt C] Clay E] Peat ❑ Sandy Loam Clay Loam "D Hardpan ❑ Adobe ❑ 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,) PACKAGE TREATMENT [ I SEPTIC TANK[ ] Size_____________________________________________ Liquid Depth ___-__-____-_---_________ Capacity ------------------- Type -------------------- Material---------------------- No. Compartments --------------...:.... Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------I ....,------ LEACHING LINE ) j 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 Q No 0 Water Table Depth ----------------------------- --------_------__Rock Size ------- -------------------•--- Distance to nearest: Well _______________________________ __!�_...Foundation -------------------- Prop. Line -_----__--______--____ REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------ pate `'1 Septic Tank {Specify Requirements) ------------------- = ---------------------- --------------- :�; Disposal Field (Specify Requirements) o__ ___- '_----- �` _--- ---- ---- -�.,--- - -----=-•-------• -r V �.- --�-----------i _ �i (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- ------- wner_ 'fit s- By ------------ F4-x { Title -------------------- - --- ---------------------------------------------- (if other than - f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ----------------------------------------------------------- ------------ DATE __ ._ ....710 -------------- BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------- -------- --------------DATE ------- ----------------------------------- ADDITIONALCOMMENTS --------------------------------- -------------------------------------- ---------------------------------------------------------- ---------•----------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- -------------------- --------------- -------- ---------------------------------------------------------------------------- - ------ ------------------------------------------------------------------------------------------------------------------------------------- ------- a- --------- ----------- - ------------ ------ - _ - -� - Date 'Final Inspection by SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M.