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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: - -------------------------------------------------------- (Complete in Triplicate) Da)te Issued -------------------------------------------- --- ' ___ .__:_.✓4_--�� This Permit Expires 1 Year From Date Issued } . Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein Regulations- described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: p�J �_x JOB ADDRESS/LOCATION ci ,40-_ -- -- e '�� CENSUS TRACT ------ -10 Owner's Name /�� t -------------------Phone !__------ --- � � - " ", City � C�ylll I's �� Address Contractor's Name - -------.License # Pho e � -- Installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court Motel ❑Other ------- ----------------------------------- _ Number of living units:----- Number of bedrooms `_2_-}_Garba9e Grinder --------- Lot Size ------------- Water Supply: Public System and name ----(,' :;--GLS ---• --------------------------------------- ----------------------------- ----Private a depth of 3 feet: Sand' Silt Clay ❑ Peat❑ Sandy Loam ❑ Ciay Loam Character of soil to p ❑ _ 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.j � NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Vt PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] 't . Size---- 5'xJ---------------Liquid Depth ��-----•----- Capacity _/ � - --- Type __1 .4-_--__: Material__��"�-t----- No. Compartments ____�-_..._.-:.___ Distance to nearest: Well ------_r`=---------------------Foundation ------------ Prop. Line __,fes---_--..-•-- LEACHING LINE [ ] No. of Lines ________f______________-Len-Length.-of each line.____/R(P-------..---- Total Length ____l ------------ g o 'D' Box _.-- -____ Type Filter Material _Rtaa� y -.Depth Filter Material _____f_____ ___________________---..__-.__ t Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -_-------------•-------- SEEPAGE PITDe[ ] p fih __og_-S_--------- Diameter Number ---------Z-------------- ___ Rock Filled Yes No Wafter Table Depth ------------------Rock Size -------------------------------- --Foundation Pro Line ---------------------- REPAIR/ADDITION _______________ • Distance to nearest: Well - ------ ------------- -------------• ------- ------------ p• -----• REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------------) , Z Septic Tank (Specify Requirements) ---------- ------`---------------------- ---- Disposal Field (Specify Requirements) --------------— ---------------------------------------------------------------- ------ ----- -------------------------------- -------- (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." r Signe ------------------------------------------------------.� Owner - ---------- -- - - -------------------- -- --- - B Title . (lf other than owner) R P RTMENT USE ONLY APPLICATION ACCEPTED BY .--- ----- - - --- ------------------------------------------------- DATE ---- ------------------ BUILDING PERMIT ISSUED --- -------DAT ---- ---------•----- ----------------------- ----- ------- ------ ADDITIONAL COMME S -- ----------------------------------------------------------------------=--------------------------- / -- ----------- - ----------- --- - __LLr�- �_�_______________ __L _ _____ __ __� _______________________-___________-________________._-_______-_-_________________-______________-___________._____.______.___-_______-___ ------------ ''"'77777 __________________________________________________________ ________________________________ ________ _ ___ _ - Final Inspection by: ---------- ------._Date ---- - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT t F H 9 1-'68 Rev. 5M f