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-� `"FOR OFFICE USE: l APPLICATION FOR SANITATION PERMIT Permit No. ---------- --------- ------------------ s (Complete in Triplicate) p Date Issued - - - --------------------------- --------------- _.._--�d -_•- 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 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS LOCATION -�- - -- ------ t:Jl �t �" --- tz_ � -CENSUS TRACT ----------------- -----1-- p_" .r-------------------------------- -------Phone Owners Name -__. _�3l-1'�----:-- --��-� " t - ------------ City .................Q-,a--T---------------------- License # ------------------------- Phone Contractor's Name R � I Installation will serve: Residence ,Apartment House❑ Commercial :]]Trailer Court lQ Motel ❑Other -------------------------------- ----------- � t Number of living units:______ ----- Number of bedrooms -__S-----Garbage Grinder -- ------- Lot Size ' -------------" Water Supply: Public System and!name -------------- ----/------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt El Clay E)//Peat❑ Sandy Loam ❑ Clay Loam ❑ W Hardpan ❑ Adobe R Fill Material -------- --- if yes,type ----------------------------- Plot Ian showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.] ( p 9 � NEW INSTALLATION: (No septic tank or seepage pitpermittedif public sewer is available within 200 feet,) I PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- I T e Material No. Compartments Capacity,--------------------- YP ------- Prop. Line ---------•------------ !I Distancel to nearest: ------------------------------------ Well Foundation -------------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ________---.-----------_-- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- '�t`S'� Distance to nearest: Well ------------------------ Foundation - --------------- Property Line ------------------•--•-- SEEPAGE PIT [ ] Depth _. ----------------- Diameter ---------------- Number --------- ------------------ Rock Filled Yes E3 No WaterTable Depth ------------------------------------------------Rock Size ---------------------------•---- `�[ 1 Distanceto nearest: Well -------------------------------------•--Foundation ---------------.---- Prop. Line ---------- ........... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____--______--_-------------.-----) I Septic Tank (Specify Requirements) ---------- - ----------------------- ------------------------- ------------------------- ..- IL Disposal Field (Specify Requirements) - Vv_ U�iv� ----- -q-n-------C�------- �} ---------------------------------------- - ---------------------------------------------------------------------------------------------- (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 bec "subbiedWa 's Compensation laws of California." Signed - ----- ---- - - -- - --------------- - - - ---------------- Owner BY . ------ ----------- ------------------ Title ------------------------------------------- --------------------------` (If other than owner) FOR ARTMENT USE ONLY k APPLICATION ACCEPTED BY ------ ----------------------------------------- -------- DATE -_ .� 0 = ------------- BUILDING PERMIT ISSUED ------- -- -------DATE ADDITIONALCOMMENTS ------------------------------------------------ ------------------ -- -J_- ---- - +- -- -------- dr - ------------------------ -- i � ---- --------- ----- -- - -- --- -- ----------------------- ----------------------------- ------------------------------------ - - -- ------------------------------------------------------------------------------------------ Final Inspection b ------------------------ Date r = JOAQUIN LOCAL HEALTH DISTRICT r Rev'-5 E .H: 9 1 '68 - -