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FOR OFFICE USE: W APPLICATION FOR SANITATION PERMIT -------------------------------- (Comp lete in Triplicate► Permit No. -""--------------------------- This Permit Expires 1 Year From Date Issued Date Issued-d ......� 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 Ordi nce No. W and existing Rules and Regulations: JOB ADDRESS/LOCATI j ----- -- � � --------------- FF77Yy� -CENSUS TRACT ---------------- Owner's Name ----___ - ------- ------------- -- -- -- --- ---- -------------------------------------- Phone-- __SAGS _., 7/4. Address ------ --------l-+�� '-�'---�-----•-C�_�_ �� - • +------------------- Cit Contractor's Name ____ --_ '� License -- -- ------ �`� � � - --- :---�------ Phone ------ -- - Installation will serve: Residence.�4partment House-E] Commercial :❑Trailer Court Motel ❑ Other -------------------------------------------- Number --------------------- -- ---- -- ---- Number of living units:--.-/----- Number of bedrooms -___�arbage Grinder _.__ _ p� C3 _Lotize ___6��?C 4- � Water Supply: Public System and name ______________ Private E]- •--------- Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ y ❑ Peat❑ Sandy Loam Clay Loam 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 [ ] SEPTIC TANK:[ ] Size------------------------------------------------ 0 Liquid Depth ----- -----------•-------- Capacity ----- -------------- Type -------------------- Material---------------------- No. Compartments ------ ... ---------- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING LINE [ J No. of Lines ----------"------------- Length of each line---------------------------_ Total Length 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ___ _ _ _ ------------- ------- Distance to nearest: Wel! ________________________ Foundation ____ Property Line EPAGE PIT [ ] Depth -------------------- Diameter —�--- ---------------- Number --------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ------- ------------------- Distance to nearest: Well _____________ ____--Foundation ---------------- -------------------- Prop. Line -.-----------•-••----- ------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- ------ Date ------------------ -----------•---I Septic Tank (Specify Requirements) ---------- Dis osal field (Specify Requirements) ------------- --------- � p (�p Y q /(f j . - �F— ` --- c -- -- --- ------- ¢' ---� -------- �2 ------------- - ----- --- ---------- - - - ---------------ired---dd-i-------------------- e------------------------------------------------------------------- (Draw ex' ing 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: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as ro bIra subje t to Wor man's mpensation laws of California." Signed ---- - .4 BY Title _ -._ (If otherthan owner ----Z-- AO------ OR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY ___ _ _ Ir 1 _--_ _ _ -------------------------------------------------------------- DATE ---- -07.14— A 0 _�4=BUILDING PERMIT ISSUED __ ___ _ _________ ---------------------------------------DATE ----------------------------- ADDITIONAL COMMENTS . ------- -------- --------------------------------------------------------------------------------------------------------------------------------------------------------- -- -------------------------------------NX Final Inspection by: _____ --- ---------------------------------------------------------------------------------------- ------------- - - -- ---------------------------------------------------------------------------------- Date r L SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M