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FOR OFFICE USE: M APPLICATION FOR SANITATION PERMIT .- w r 7-------------- ,Complete in Triplicate) Permit No. - ----------------------------------------____-___ -- This Permit Expires f Year From Date Issued Date Issued __ ." ' 75f 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 Ordirwance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION<?p_F76_d ---- -__ -- .0 �' - © -- ----------------- -- -� --------CENSUS TRACT --------- Owner's Name ._ -f1�_-_/ �a _--__ ----------------Phone - ."'_r ' ---- Address l ---!61,X11--�?D /� ------ ----------------- City Contractor's Name 4 - -•_-- �4_�ZIle---------- License cl. 11.___--- Phone t7�_Q__ -_-�. Installation will serve: Residence Apartment House-E] Commercial [:]Trailer Court Motel ❑ Other - ------------------ Number of living units:....<____-- Number of bedrooms _______Garbage Grinder ------------ Lot Size f •17 ___________________. Water Supply: Public System and name ______________.___---. __.____.---------_-_-------Private 17F Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ 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,) ly PACKAGE TREATMENT [ ] SEPTIC TANK L ] Size------------- --------------------- - -/!-- Liquid Depth -------------------------- 0 Capacity -------------------- Type -------------------- Material/-------------- No. Compartments -------11----------- 00 Distance to nearest: Well --------------------------------- -•Foundation./-------------------- Prop. Line ----.-----------.----- S LEACHING LINE [ ] No. of Lines _______________________ Length of each ine--___________.------------- Total Length 'D' Box -_.__._____ Type Filter Material _______ ___________Depth_, Filter Material --------------------._____...________._____. kA Distance to nearest: Well --------------------- - Foundation--------------------------- Property Line ----------------------_ SEEPAGE PIT [ ] Depth -------------------- Diameter -____-- -____-- Number .--------------------------- Rotk Filled Yes ❑ No i❑ Water Table Depth --------------------- --------------------- --Rock Size -------------------------------- W -------------- -------- U Distance to nearest: Well ------ -- ------------------------- -•__F ndation __.____-_----------- Prop. Line ------_----------•---- REPAIR/ADDITION{Prev. Sanitation Permit# _______.--__ ___________________ Date ---------------••-------------_-__) Septic Tank (Specify Requirements) __________________ __ ------ .� - Disposal Fiel (Specify Requirement ------ - --••-- ' '" ----- -------------------------------------------------------- ------------------------------------------------------ ------------------------ --------------- ---------------------- ------------------------------------------- / (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 o Wor an's Compensation laws of California." Signed ----- - ---- --- --- Owner 'd BY -------- - ----- ---- ---- ------ Title ------------------------- (If other than owner) FOR DEPARTMENT USE ONLY ., gg APPLICATION ACCEPTED BY ----- -------- ------------------- -------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ------- ---------- - - -----------------.DATE -- ADDITION AL COMMENTS ----------- - ------------- --------------------------------------------- ---------------------------------------------------------------- ---------------------------------------------------------- ------------------ ------------------------------------------- -- --- - -- ---------------- ---------------------------------------------- ----------------------------- ----- Final Inspection by: ---------- ------- -----Date ----- — _V!1 - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M