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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -----=----------------------------- Permifi No, _ 0-�Be (Complete in Triplicate) -- ------------------------------ Date Issued T_-_4- ------------- ------ ---------------------7--------------- - -"--------------------.----__------------------_--._--_-- This.Permit Expires I Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 3S`0 n'- ----- ---- �i-'''e2"t---------------------------------------CENSUS TRACT -------------------------- Owner's Name -------- --------------------------------------Phone ------------------------------.----- "" Address -------- Jd�► 9 ------- �1 1 -- -------- City ° QT"`" Contractor's Name - f' / --4�;�----- License # Phone f ''�'"-'�r� Installation will serve. Residence Apartment House❑ Commercial :❑Trailer Court !0 Motel ❑ Other ---------------------------- -------------- - 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 ❑ rSilt.0 Clay ❑ Peat E] Sandy Loom -E] Clay Loam,Q Hardpan ,� Adobe ❑ Fill Material ----- ------ If yes,type --_-_--__-?_-__-__---_- F (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,) (� t PACKAGE TREATMENT f ] SEPTIC TANK [ ] ' _ Size------------------------------------------------ Liquid Depth'{------------------------ Capacity -------------------- Type --------------- Material---------------------- No. Compartments ----------------- C Distance to nearest: Well ----------------------------------Foundation - -_______ __ ------ Pro1p• Line ______________________ � LEACHING LINE [ ] No. of Lines ------____--_-_______ Length of--e'ach line--------------------- Total Length ------------------------------ Len ! ------- ------- --•------- - r ---Depth Filter Material -_____-- _-_- 'D' Box ---- ------ Type Filter Materia! _______.__�---_- Distance to nearest: Well ---7- ------- Foundation ---------------- ------ Property Line. -----------------........ - SEEPAGE PIT [ } Depth --- Diameter ---------------- Number ----------------------- Rock Filled ;.Yes [] No .I❑ WaterTable Depth --------------------------------------- --------Rock Size ----------------------------- Distance to nearest. Well ------------------- ----_-__Foundation- :---__-..7�- __ Prop. Line -------------- ....... REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------ Date --_-_---.--..-.-..__-_----__-_--_-) r SepticTank (Specify Requirements) -------- ------------------ -------------------t----------------------------------------------------------------,.--------------- ------- Disposal Field (Specify Requirements) n Y (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 ------------- ---------- ------------ �i -------- `--- -------------------- (If other than owner) FOR .DEPA:RTMENT USE ONLY APPLICATION ACCEPTED BY ------ - ------------------------------ DATE - `f 9 - BUILDING PERMIT ISSUED ------- ----------------------------------------------------------- ----- _DATE ------------------------------ ADDITIONALCOMMENTS ------- -------------------------------- -------- ------------------------------------------------------------------------------------------- - - ---- - - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----------------------------- ------- = - - ------------------ Final Inspection by: ------ c Date 1 `7C3 SAN JOAQUIN LOCAL HEALTH DISTRICT - r� E. H. 9 1-'68 Rev. 5M