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FOR OFFICE USE: f% �J� APPLICATION FOR SANITATION PERMIT Q-------- �`1 Permit No (Complete in Triplicate) --------------------------------- This Permit Expires 1 Year From bate 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: JOB ADDRESS/LkOGATION ------o4_Y�-�_ _-__ ------!- ... _- -- -- v CENSUS TRACT -------------t-------•---,------- Owner's Name ----- ---Phone T 1 / Address _�_ J City ! Contractor's Name ._�'A_._`Y.l� i'Ndf 4---mSr 74 �_----License # __ _...._ Phone 7��_`��{�6./.___. - f Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court !❑ jN10141_❑ 6ther ------------------------------------ -•- Number of living units:........... Number of bedroos-- 1_.._Garbage Grinder ------------ Lot Size ................_.--_------------.._....._. r Water Supply: Public System an( name --------------- - ----------- ---------------------------Private ❑ Character of soil to a depth of 3 feet. Sand'❑ Silt-E] Clay ❑ Peat❑ San y Loam ❑ Clay Loam r� i f r HardPt an,❑t Adobi:'�❑ Fill Material --------- -- if yes, type _________________-_________ � } I {Plot plan, showing size of lot lOCgti'�)n._of ystem in relation to wells, buildings,.et�must be placed on reverse side.) NEW INSTALLATION: {No septic tank oseepage pit permitted if public sewer is available within 200 feet,) ! PACKAGE TREATMENTI [ ] SEPTSize-------------------------------- i- Liquid Depth -------------------------- � _A_�IkV ' ----- --------------- ` Capacity ------ -------- -- Type ........- Material--__---- No. Compartments Distanc6• to nearest: Well -----------------------------t-----Foundation ------ -------------- Prop. Line ---------------------- LEACHING'LINE• No. of Lines =----------------------- Length of each line---.------------__._-_.__ . Total Length ..-._...__.•.....______.____ 'D Boxl -------- --- Type Filter Material --------------------Depth Filter Material -------------------------------------------- - I Distance`\ to netarest: We'll_ =.._ ------- Foundation ... i. ._.. .-._ Property line ------------------_--- SEEPAGE _-___-._-._-_-- --.SEEPAGE PIT [ ] Depth !-..---.--� Diameter ....... ...... Number ----------------------- .--- Rock Filled Yes "❑ No IQ I t fL Water Table Depth ------------------------------------------q-----Rock Size -------- i DistafiCei to nearest: Well _ __Foundation .................... Prop. Line -------------- ....... i - --------------------------------_ _._._.__._._. ------------------------------------ Ia REPAIR./ADDITION{Prey. San��at on Permit# ____________ Hate Septic Tank (Specify Requirements) __-__-_ __ ____ .._ .&V Disposal Field (Specify Requirements) -- ----------------------------- 41 Ile �- ---- ---- -- - ---- ---- ------ ---------- ---------------------- -------------------------------------------------------------------------------------- ---------------------------------------------------- - ..__A._ _(Draw.existing and required addition on reverse side)„ I hereby certify that 1 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 t ------------- Title --- ------------------------------------------------- ---------------- (If other a owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------------- -- ------------------------------------------------------------------.----. DATE ------- -------- BUILDING PERMIT ISSUED ------------------------------------------------------------ --- ----------- ---- ---------DATE -------------------------- --------------- ADDITIONALCOMMENTS - --------------------------------------------------------------------------------------------------------------------------------- --------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------- ----------------------------------------------- ----------------- --------------------------------------------------------------------- -------------------------------_---------- ----------------- - - - - - ---------------------------------- -- Final Inspection by: -- -------------------------------------------- ------------------------------------------------- Date -----�---- -- ------��- - - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M