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FOR OFFICE USE: - APPLICATION FOR SANITATION PERMIT ,. {Complete in Triplicate) Permit No. �W_/Ga/ --------------- This Permit Expires 1 Year From Date Issued Date Issued �_Z__167-61. `Application s7hereby=m6de-t6 theSan 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. /�. --,D30-o JOB ADDRESS/LOCATION 1"d,f� _ - - -- --- - ------�----""`""�--i7_-- - -------�/---�1��-'�..__ '_---CENSUS TRACT ---------------------•--•- k Owner's Na -------- ---------- -- ---------- Phone w -- ------------------ ----------- - Address ----- --- "cid Cit •------R Contractor's Name --------------------- ------- _-- --- _- --.License # ---- y/73___-- Phone Installation will serve: Residence ❑ Apartment House❑ Commercial:Zraller Court ;❑ Motel C]Other -------------------------- Number -------- -------------Number of living units_____________ Number of bedrooms ----------Garbage Grinder ------------ Lot Size - --------------••-- Water Supply: Public System and name ---------------------- -------.___-----Private Character of soil to a depth of 3 feet: Sand❑ Silt F1 Clay .❑ Peat F] Sandy Loam Clay Loam:❑ '' t Hardpan F] 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,) - - PACKAGE TREATMENT [ ] SEPTIC TANK'[ ) ---Size---------- --- --------------- - ------ Liquid Depth -------------------------- � - j Capacity -------------------Type -------------------- Material---------------------- No. Compartments t--- ------------•-- ---Foundation Distance to nearest: Well -----------------------Prop. Line ;.• ------------ ' LEACHING LINE [ No. of Lines ------------------------ Length of each line______________ _________ Total Length ` t D' Box _ ________ Type Filter Material ____________________Depth Filter Material ___{_, "__=._�__.__. _ .........___._ Distance to nearest: Well _______________ i ,� ______ Foundation ______________________ Prop@rty .Line _______ .-•--- SEEPAGE PIT L r [ ] Depth -----�--------------j Diameter -----------__-- }Number ----------------- ---------- Rock Filled Yes ❑ Na i❑ Water,Table Depth --------------------------------:'--------------Rock Size ------------------------- -- .Distance to nearest: Well ------------------- ---------------Foundation -------------------- Prop. Line -----------------• I REPAIR/ADDITION{Prev. Sanitation Permit# _______-._______.___-_______________._____ Date ______--__-_______-__....________) i • .� Septic Tank (Specify Requirements) ------------------------- - -------------------------------------------------- - - - Disposal Field {Specify Requirements} _-- l�e�" 1 , ..r _ -- --------------------------------------------------------- ---------- ------------- �F --------------------------------------------------------------------- -------------------- ---------------------------- --------------------------------------------------- ----------------------------------------------------- (Draw existing and required addition on reverse side).,,,,,,,•,-- _ I hereby certify that I have prepared this application and #hat 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 ollowing:."I certify that in the performance of the work fol"hick this permit is issued, I shall not employ any person in such manner as to beco a sub'ect fo W km 's Compensation laws of California." s t Signed ____ Y _ Owner - ---- ----- - ---- ,V - BY - ---- -------------------------- � _!�_�. ,title ---------------- (If other than owned i FOR DEPARTME . U ISO Y j APPLICATION ACCEPTED BY -- = ------- ---------------- DOTE . 1- -- --- ---- ------ ------------ BUILDING PERMIT ISSUED ---------- -= - ATE -------- ---- ---------------------------- ----------- - ADDITIONAL COMMENTS -------------- ---- - --- --------------- - -------------------- ------� ------------------ - --------- - .. --------------- . ------------------------------ ------- . --------- --------------- Y -------------- - --- -- ------ ------- ----- ---------- --- - ------ _____________________________________________________________________________ _ _ __ - _ _ _ __ _ ______ -- -- --_ ----- - Final Inspection by- --------------------- ---------------------- -- -- ----- ---- ----- - ----------.Date -- -------------- SAN A UIN L CAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M