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FOR OFFICE USE: f`4�: X^ `! Io F APPLICATION FOR SANITATION PERMIT 1 (Complete in Triplicate) Permit No- --------------------- This Permit Expires 1 Year From Date Issued Date Issued /1 - 7:?- 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 ..___ Cplay W_,VV�--------k?-t----------------------------- ----------- -------- ---------CENSUS TRACT Owner's Name ---------a- ro----Al h__ 6cln)--------------------y------------------------------------_- --------------Phone Address 1d'G 0t 0K4� �'x._R 1 .Z ( City L1'AG_ _ { ------------ Contractor's Name __�Q4,.__ U��-('/ -----------------------------------------------.License # _ _7t _ Phone Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ 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 Q Silt❑ Clay ❑. Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type -----------------__ W (Plot plan, showing size of lot, Iocatign 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 [ ] SEPTIC TANK[ ] Size------------------------------------------------ Liquid Depth _-______----___ Capacity ___,__ Type ____________________ Material___________________ No. Compartments Distance to nearest: Well ___________________________________Foundation ----------------------prop. Line ...................... LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------------------- ------ Total Length ,_____-___-_ 'D' Box ___ ------ Type Filter Material ____________________Depth Filter Material -------------------------------------------- Distance to nearest: W6TT-________ _------------ ' Foundation ------------------------ Property Line -------•-•_--- -------- SEEPAGE PIT [ ] Depth ---------:---------- Diameter ___-_-_____-__- Number _______ ____________________ Rock Filled Yes ❑ No Cl Water Table Depth ------------------------------------------------Rock Size -------------------------------- W Distance to nearest: Well ________________________________________Foundation ___________._ --. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -______-___-______--•-____•-._____) Septic Tank (Specify Requirements) _______._______-.________________ Disposal Field (Specify Requirements) ------- w' ------------------------- ------------------------------------------------------ -------------------------------------------------------------------------------------------------------- -------------------------------------- (Dr - -------------- - (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, 1 shall not employ any person in such manner as to become subje t toWorkman's Compensation laws of California." Signed ----a`- ---- -- -------------------------------------------------------- Owner BY ---- ------------------------------ ------------------------------------------------------------------ Title ------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------------- -------------------------------------------. DATE ------------------------ DINGPERMIT ISSUED ----------------------------------------------- - -----------------------DATE ------------------------------------ -- ------------------------------ ITIONAL COMMENTS _____________________________________ ------------------------------------------ ---------------------------------------------------------------- ---------- - ------- ---------------------------------------------------------------- ------------------------------------------------------•------------------------ ------------------------------------------------------------------------------------------------------- Final Inspection b 0IN?P Y -- -------- - - Date - `1 SAN JOAQUIN LOCAL HE H DISTRICT E. H. 9 1-'68 Rev. 5M r