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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit -------------- ------------------------------------- (Complete in Triplicate) 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 County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION ._b7_1J_C1Z-_- n-tvd-_.____-4-d-_�z Cf-/ .----S -CENSUS TRACT __-__----------------__ �, 'L2 t�- - s --------------Phone Owner's Name fZ-L Address d 0Q d � r s 'Al �- -d--- f . City Contractor's Name --- _. .__ - .,_ ---------------------------License # _______________________ Phone ?/7'3-'------` Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- Number of living units:_________ Number of bedrooms _____-___Garbage Grinder _______ Lot Size C �QQ------------------- Water Supply: Public System and name �?f�!_ 1_�Y/_/ __f.?.t.t',t_ekc, _L/ k,16-__- ivate ❑ Character of soil to a depth of 3 feet: Sand❑ Silt F1 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ Adobe ❑ Fill Material ------ ----- If yes,type ____________________________ (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,) tp PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------- -------------- ------- Liquid Depth ._-----_--_-___--__,..__._� Capacity ----------------- Type --------- ---------- Material--------- ----- No. Compartments _..................... P Distance to nearest: Well _________ _________________________Found _ __.__-_._-______.___ Prop. Line _______-_..__ ........ P LEACHING LINE [ ] No. of Lines ____._________________ Len th of each line------------------ ___-_- Total Length ,____---_................. 'D' Box .__________ Type Filter Mat rial --------------------Depth Material -------------------- ....................... L Distance to nearest: Well _-___-._. -._.-__-__ Foundation ._ -.- ___.__- Property Line _____-..-_............. T SEEPAGE PIT [ ] Depth _-.__________--.__- Diameter _______________ Number _______ ___-______---- Rock Filled Yes ❑ No 0 WaterTable Depth ---------------- ---------------_----_-----Rock S ------------------------------- Distance to nearest: Well ________ ______________________________Found ___.____.____..... Prop. Line ...................... S REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ----------------------------- Date __ ___________---------.-_Septic Tank (Specify Requirements) ------------------------------------------------------------------- ------ ----------------------------------------------------- --- Disposal Field (Specify Requirements - l _______.- - ------ ------ - ------ VV �snf --------------------------------------------------------------------------------------------------------- ------ 0 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared'Ibis 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 -DEPARTMENT YSE APPLICATION ACCEPTED BY -----------------------------------------------� DATE -- --------- - ------- -------- -- BUILDING PERMIT ISSUED -- ------- -------------------------------------- -------------------- --- ----- - ---DATE ADDITIONAL COMMENTS ---------------------------------------------------------------------- ---------------------------- --------------------------------------------------------------------------------- -------------------------------- - ------3_4_-�i-------------------------- _..----- - ------ ------------ ---- ------ ----------- -------------- •- --- - ----- ---- -- -- %f- - - - - -- -- - - --• -------.-. -•--- -- - ------- - - _ ___ Final Inspection by: ----------------------- ------------------------------- ------------------------------ � / -------Date __ -/----- SA --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M