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FOR OFFICE USE: gl'pLICATION 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 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 r__C,�OS _ fi-`-----------CENSUS TRACT -------------------------- Owner's Name -----Wr _1111AVV-1 AtV) kt< _ 4------------------------------------------- ------ ------------Phone �'� ,3-J_ Address ------- - - ---------- Cit M-09 i 'G`iYY--- _ Contractor's Name __-_ ./____ _ 'l-/ _______________________________License # -7r_ 9� - Phone _r �_ Installation will serve: Residence 5?Apartment House,[] Commercial ❑Trailer Court ;❑ Motel ❑ Other ----------------------------------------•-- Number of living units:______ Number of bedrooms ______Garbage Grinder ------------ Lot Size ._ .__ ----_______________ Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private 5? Character of soil to a depth of 3 feet: Sand'g Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 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 is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK.( ] Size----------------------------------- ________ Liquid Depth -------------------------- XJ Capacity ____________________ Type ____________________ aterial---------------- _ No. Compartments Distance to nearest: Well --------_- --------------Foundati n _.-------------------- Prop. Line ---------- LEACHING ------- .-•-•--- N LEACHING LINE [ ] No. of Lines -______________________ Length o each line------------ _ Total Length -----------_................ 'D' Box ------------ Type Filter Material ___________________Depth Filter Material _____-________________________--------.--_-_ Distance to nearest: Wel! ________________ ______ Foundation _ ._ Property Line SEEPAGE PIT Depth -- Diameter ________- Number ____ _______________.____ Rock Filled Yes Na Water Table Depth ---------------------- ----------------•-------.Roc Size ----------- ------------------- Distance to nearest: Well ------------- --------------•-------.---Fo ndation -------------------- Prop. Line ----------------.--__ REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----- ------------------------ Dat ----------------------------------) Septic Tank (Specify Requirements) --------------------------------------------------------------- ------------------------------------------___---------------------------- - Disposal ----------------------•---------- ------.--------------------------- ---- Disposal Field {Specify Requirements) •.__� __ _� ___. 1_�N�-_ ____c1'fo✓I -S� --/ V---4Z0---. -----�i� % (,ct� 10L6-------- /�v----- �1'¢--------- r �-------- ---------••--------- -- ------------------------------------------------------•-•---•44=•-------------------------- - ---------------------------------- -------------------------------------------------------------------- (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: w " "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in suc `i+'ttnner as to become subject to Workman's Compensation laws of California." Signed --- --- -- ---- -- --_--_ Owner P ------------ ---- By ------- - ---- ------- ----- Title ----------------------- ------------------------------------------------ (If other than owne 19 Q FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- -------------------------------------- - ---------------. DATE ----- --------- - BUILDINGPERMIT ISSUED -------- --------------------------------------------------------------- ---------------------------------DATE ------------------------------- ----------- ADDITIONALCOMMENTS ------------------------------------------------------------------•---------------------------------------------------------- --------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------- -------------------- - Final inspection by. ---------------- Date -/C'-'1 ------- ------- ------ -- -- - - --------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M