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a POD I sa r-A-fr FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - --------------------------------------------------------- i12 �� (Complete in Triplicate) Permit No. --------------------------------------------------------- '1 qq _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued ---- 75� 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: l JOB ADDRESS/LOCATION . 4VA11 LOT A P �'? -- - -----------CENSUS TRACT .......................... Owner's Name ------------------�-- -----.------------ Phone Address ------ p ------ - '_�`2'' - --•--. City .�' ---------- p --------- Contractor's Name _. _._._1:7*1_- 6 711--___-- Phone ------- ---- ----- -- --------.License #�6e�-------- Installation will serve: ResidenceX Apartment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number ------------------------------- -- -Number of livingunits:__.____ Number of bedrooms _ �"O Jr/d!,_____.._______--%o Garbage Grinder ______.___ Lot Size ________________________ ___ Water Supply: Public System and name --------------- r740?-------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,14 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 spit permitted if public sewer is available within 200 feet,[) to PACKAGE TREATMENT [ ] SEPTIC TANK [eep Size---- 14-.X--------_------------ Liquid Depth /_.�.........., Capacity ---1-4200 Type 16RM 5_Material___ �____ No. Compartments ._'"............... Distance to nearest: Well ----- Foundation ____` __________._ Prop. Line ._..___.__._.________. LEACHING LINE V--�No. of Lines ________________________ Length of each line---------------------------- Total Length ............................ F1L_7-E& Jq&p 'D' Box ___/------ Type Filter Material ____________________Depth Filter Material �1.I Distance to nearest: Well ________________________ Foundation ------------------------ Property Line -____-__--_-___---._.--_ SEEPAGE PIT [ ) Depth _--___ ------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes No Water Table Depth ------------------------------------------------Rock Size -------------------------.----- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... 1 REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------------------------------_) SepticTank (Specify Requirements) ---------------------------------------------------------------------------- ----------------- -------------------------------------------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- t ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------- ------------------------- --- ------ - ------------------------------------------------------------------------------------------- (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: "1 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 Compeg�ation laws of California. �f -' --- Signed ---- - -- - -�---� ----'--- - - - -= `-----�------------------------------ Owner By --------- -� - -- ------- ------ Title ------------------------------------------------------------ f other than o FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- _R__O----------------------------------------------------- DATE ------ BUILDING PERMIT ISSUED ------------------------------------------------------------ DATE ADDITIONALCOMMENTS -------- ------------------------------------- -----------------------------------------------------------------------=--------------------------- -------------------------------------- -- ---- ----------------------- -- -------- ---- - -------------------------------------------------------------------------------------------------------- -- --- --- ---------------- ------- ------------------------ ---------- ----- -- ----------------------------------------------------------------------------------------------- --------------------------------------------- ------- -------------------------------- --- -- - - - - - - Final Inspec - - - - - - -------------------------------- _Date - --- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M