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FOR OFFICE USE: ,} .__ d..__ APPLICATION FOR SANITATION PERMIT -- " _ `� *4W (Complete No. C�-`/� (complete in Triplicate) -,-• --- ------__________-- ------------ ---------- chis Permit Expires 1 Year From Date Issued Date Issued _5._�?_7�y 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: � .7. JOB ADDRESS/LOCATION / ---- --------- - - ------- --� - CENSUS TRACT _ - Owner's Name 1�� ---- ---- J------------------------ ---- Phone Address - City --- ' --------------------------------- . I j) , Contractor's Name .. G !L�L - ' C}L`'-'`'2i .-- -.. ..License #�&Z-57-L/----- Phone �7�� --y�� . Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court .❑ Motel ❑ Other __ _ - _ . -------------- Number of living units: /._ Number of bedrooms ____1..._Garba e Grinder -_ Lot Size ..-_"�--!�'_c' -_---._.._--_ Water Supply: Public System and name - --- - - -- ---- - ---- ----- --- ----------------Private X Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material If yes, type ... ........ _---------- 'A -_ --.-- (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,) It, PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size _- - _ _ _. ._ Liquid Depth Capacity . - Type --. --- -. . Material- . No. Compartments ------------------.-- Distance to nearest: Well ___ - __ _ ._-Foundation ___ Prop. Line . _______-.__._.__ LEACHING LINE [ ] No. of Lines __ _ ___ _. _ Length of each line - - Total Length --- ---.------------- .. ` 'D' Box _ ___ Type Filter Material ...._._ ------- Filter Material .. _. -------_-_____-____._.. Distance to nearest: Well __ _- Foundation _ ----- - _ ----- Property Line .._ - PIT [ ] Depth -- Diameter ------- Numbe- -__----------_. ------ Rock Filled Yes ❑ No j] 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) ..-__-____. __-- v 1 - -- - ------------------------------------------------------------------ ----------------- -------- ----------------- ------ - - - ------------------- -------- ------------------- ------------ - ----. . - (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 ---------------- By - - Title -- r- - - -- -- (If other1lan ed FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------------------------- ------- -------------- ----------- DATE - ------------------ --- - ----- ---- BUILDINGPERMIT ISSUED - -------------- ------------------------------------------------------------------------ ------DATE --------------------•--- --------------- ADDITIONALCOMMENTS ----------- -------------------------------- --------- ------------------------------------------------- ------------------- -----------------•------------ --------- -- -------------------- - ------------------------ ------------------------------------------------------------------------------- ----- ------ --- -------------------------------- Final b Inspection r.. f� 70 P Y % - ----- ------ --- -------Dat_P _ . - ------f�---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M