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fpR OFFICE USE: APPLICATION FOR SANI'T'ATION PERMIT ---------------------------------- Permit No. (Complete in Triplicate) ------------------- ------------------------------------- --------------------- -------------:---------------- This --------------- -------------------- 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: 100, JOB ADDRESS/LOCATION ------- ----- --- 1 - ------- --- ------- ---------- ----CENSUS TRACT -------------------------- y Owner's Name fx1�✓L dye --------- -------5'!{ 0 0, :-------------------Phone Address ------ - olt ------------ ---. City. - Contractor's Name --------�- �-�e,-.-c.- ___--"' -- -------------------------------License # 1_`1'_ '_.__ Phone//X, - Installation will serve: Residence kApartment House❑ Commercial ❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- � Number of living units:_-__._ _____ Number of bedrooms ___,____Garbage Grinder � __ Lot Size --- Water Supply: Public System and name ---------A� --------4-AG 'I--------------------------------------------------Private❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ j Hardpan ❑ Adobe ' Fill Material------------lif yes, type ---------------------------- k (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,) i 4 PACKAGE TREATMENT ( SEPTIC TANK j Siz/e- - �_ �_ — ---- - _______ Liquid Depth _____'�......-,____. WCapacity`:s "_c9�Type X _ terial___ _ No. Compartments ___ _____________ Distance to nearest: Well _- e___G__��-�'�______Foundation __A ,� --- ____ ____ ?Tp. Li �;�....�....... OU LEACHING LINE ' No. of Linesf ��---�____-____ Length of each (i e-_ -_� f,� -� elifgt ....................... r D' Box .__ __-__ Type Filter Material __Depth f=ilter aterialF__------------------- ______ Distance to nearest: Well -__ A Aoundation .../ _ .......... Property Line. :.U�-----f SEEPAGE PIT ` ' Depth _ S"r____ Diameter Number _-_:�__________________ Rock Filled Yes dr No 0 Water Table Depth ----------5-, -----------------------------Rock Size --------1�7-------------------- ��_ __Foundation __l�_ _____ Prop. Line ____��__.-- Distance to nearest: Well __-,?✓________________ �_ _. � � REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------- .___._-...- .......... Septic Tank (Specify Requirements) ------------------------------------------------------------------------------•---- _< -------------• ----_- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------ ------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------ ------------------------------------------------------------------------------------------- --------------- ------------------------------------- ` (Draw existing and required addition on reverse side) 1 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 to become subject to Workman's Compensation laws of California." Signed ------- ------ --------------------- -------------------------------- --------------- - Owner By ---------------- -------------- - �' t Title -------- ---- r.4---=----------------- (If other than owner) /;�"EPARTMENT USE ONLY APPLICATION ACCEPTED BY --____ Y BUILDING PERMIT ISSUED - --- ---- ------ - ------- -------------------------`---------------------------- --------DATE ------- --------------------------------- ADDITIONAL COMM TSS- - _-- _ ------------------------------ ----------------- ----- - ---- - -- ------------------------------------ ----------------------------------------- - ------ ----- - --------------------------------------------------------------------------------------------------------------------------=------- FinalInspection by: --------- ------------------------------ ---------------------------------------Date -- = �\=�Y---------------- SAN�JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68.Rev. 5M