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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------ Permit No. (Complete in Triplicate) ___ ----------------- 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 complicince with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSfLOCAI N _ CENSUS TRACT ------------ ------------- Owner's Name Phone /. �`! �} -- ----- ------------ - Address --lS 'G/ � ------ --------------- -------- City City - f C-c� S ." - 6a Contractor's Name ------------- --- ----------------------- # y Phone = Installation will serve: Residence KApartment House f-1 Commerciai ❑Trailer Court l❑ Motel ❑Othbr -------------------------------------------- / Number of living units:..-..t ---- 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❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hordpan`�Z 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.) r :. NEW INSTALLATION: {No septic tank or seepage pit permitted`if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------ ---------------------------------- Liquid Depth --------------------------- Capacity -------------------- Type ---------------- --- Material No. Compartments ---W I Distance to nearest: Well, ._'_----------------------_Foundation .....----------------- Prop. Line --------..------------ /y tom`le, 4� LEACHING LINE [ ] No. of Lines ----- -------------- of each line.. _ ------------------ Total length ----------- ---------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material _---....._-_.-...-_-..--------------.---.--(,� ts Distance to nearest:'Well ------------- Foundation A ------------------- Property Line ------------------- SEEPAGE PIT [ ] Depth ------------------- Diameter ------------- Number, :�------'tA-- ----------- Rock Filled Yes ❑ No ❑!!! Water Table Depth ---- ---------------- =-Roc k Size'-------------------------------- G --+-� . . I Distance to nearest: 1Ne11 ------------ ---� ...Foundation -------'�----------`Prop. Line .............--- r ----------- Dates k,i�+-—- --- 1 J REPAIR/ADDITION[Prev. Sanitation Perrrnt'#:..------------------------------- ---------------- Septic Tank (Specify Requirements) ---------------------------A------ - - ------� - - i Disposal Field (Specify Requirements) ----- --- �" = --- --�� ---------------------------------------- { ------------------- ---..53— a Y-tea Cts'`-a-- ----------------------------------------------------- -------------------- -------- ---- ------- ---------� -----J. --:------- ---------------`1: --�--------------------------------- (Draw existing and required addition on reverses_ide3 , ' I hereby certify that I have prepared this application and that the work will Ibe done infaccordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of-the San-Joaquin Loca`1'Healfh District. Home owner or licen- sed agents signature certifies the following: 1 i �. t� "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." X Signed-- - -- --- -_-------- — - -------- - -- - 1 k --------------- Owner r --------------------------------- Title - ---------------- -------- ( othe n owner) �•. FOR DEPARTMENT USE ONLY APPLICATION ACCP ED BY ----- -------` -----------yr � ��`=--------------------- ------------------------------- DATE - �. ..�°� -- E -' = i BUILDINGPERMIT ISSUED ------------------------ -------------------- ----------------------------------------------------------DATE ------------- ----------------------------- r ADDITIONALCOMMENTS --------------- --- ----------------------------------------------- ---------------- --------- ----------------------------------------------------------- ---------------- --------------- ---F __ ------- ------------------------------------_----------------------------- ----------- -------- Date - ` !� 7� 3 --- --- - - - - Final Inspection by. ---- ------- -------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M