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Fr)R OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------ ------------------- io � (Complete in Triplicate) Permit No. ----------•- -------------------------------------------- _________________ _________________ This Permit Expires 1 Year From Date 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 rounty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION __ _ .-a�,�__------ A, -----,�G f. ---------------------------CENSUS TRACT --------------_----------- Owner's Name - Phone -- -�- -- /^� Q�''- Address _ �-iA,0------- ------ -------------------------------- City .��t.1--� .-r--- Contractor's Name ---------------------•------------------------------------------------------- ---------License # -------------- --------- Phone Installation will serve: Residence ['Apartment House-[] Commercial 10Trailer Court Motel ❑Other --------------------------------------------G f / f Number of living units_____________ Number of bedrooms __. rba--a Grinder ___I_------- Lot Size 6_ __,K__ _f��t_�_�_______ y Water Supply; Public System and name ____ -------------------------------------------------Private Character of soil to a depth of 3 feet: Sand' Si9t Clay Peat Sand Loam Clay Loam p ❑ ❑ Y ❑ ❑ Y ❑ Y ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type --------- ------------------ (Plot ------------- --(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 isovailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK Size.../7r_�_`J----- ____________________ Liquid Depth --------------------------- Capacity ________._________,. _ Ca acitY -- ------------- TYpe ____________________ Material---------------------- No. Compartments ... . 0 Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines S----------------- Length of each line_____S_r___.______ Total Length ._ _ ....... 'D' Box ___ ZC� Type Filter MaterialDepth Filter Material _________._______ ....................... Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ___-_.-__•---_-__-____- SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number _________________________ Rock_U e-d Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation ---------------.---- Prop. Line __________--__----__-- REPAIR/ADDITION(Prev. Sanitation Permit# -.------------------------------------------ Date ----------------------------------) SepticTank (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." Signed ----------------------------------------------------------- Owner BY --------------------------------------- ---------------------------------------------------- Title --- -------- -------------------------------------------------------- (If other than owner) FOR_PEPARTJ119USE ONLY APPLICATION ACCEPTED BY ---- ---------- ----------------------------------------- DATE ---Z-1 -'------ -------- PERMIT ISSUED ------------------------- - --------DATE ' ------ -------•I------•--------- --------- ---- ---- ADDITIONAL COMMENTS ------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------- Final Ins-ection b : ------ ---- -_f---- -- ----- ----------------------------------------------------- -----------------------------------;0--4:1-;-7 ----- .-- ---- ---------------- p Y --- --------------- ---- --- - -- Date � "%�Zf SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M C��.�