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N w FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. __.7� _�r__ .__ O_ _. __ _________________________________________ ___-- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION __$f s-d----- - CENSUS TRACT Owner's Namet = Phone Address ----- © -/- v-ct -------------y---- -----. City t -------------------------------------- Contractor's Name -.--C,�+-r--�----- ---- -------------- + .----f''� ---.License # �-- Phone------------------------------- Installation --------_----._------Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Mote! ❑Other ----------------------------------- -------- i Number of living units:------ ---- Number of bedrooms ___47__Garbage Grinder ------------ Lot Size ---- 4 ................ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------- jt Character of soil to a depth of 3 feet:* Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam V Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type _________________________ (Plot plan, showing size of lot, location of system in relaiion 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 { ] If SEPTIC TANK - Sizet' � __� _-.X___�_-__-_____---_._ Liquid Depth ____ __________________ y W Capacit4l_Db _ Type�L_�___-_-_-----� _____ Material - - ____ No. Compartments ____5______________ Distance to nearest: Well lT _.rO_________.__.___-_Foundation _._.t_4___________ Prop. Line ___4 .............. LEACHING LINE [Xj No, of Lines _________ ________-__ Length of each line-------- 01 --- 4_____.____._ Total Length ,___-�S _........_.__ 1� 'D' Box ----I------- Type Filter Material ____ -----Depth Filter Material --------I__q__li________________.......... -� Distance to nearest: Well ______— ._______ Foundation -____._.1-101__.__ Property Line ____- ... _. SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes E] No Water Table Depth ------------Rock Size ________________________________ Distance to nearest: Well ----------------------- -------....Foundation -------------------- Prop. Line ...................... IMPAIR/ADDITION(Prev. Sanitation Permit�# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------ - -- ------------------- Disposal Field {Specify Requirements) ------------- -------------------------------------------------------------------------------------------- --------- ------------------------ -------------------------------------------------I------------------------ ---------------------------------------------------------------------------------------------- {Draw existing and requiredadf dition 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 .- +� (If other than owner) JEOR DEPARTMENT USE ONLY �^ APPLICATION ACCEPTED BY ----------------------------------------------------------- DATE ._----------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------L------------------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS - -------------------------------------------------------------------------------------------------------------------------------------------------' ------- ---- - - ------- ----- - Final Inspection by: -------------------------------------------------------------------------Date. - 7�.r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM