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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------- ------------ ------------------------------ (Complete in Triplicate) Permit No. _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to tke'San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordin nqe No. 549 and existing Rules and Regulations: 3 0, v--� lC4 s s.N 6 JOB ADDRESS/LOCATION -4f;&O-------_CENSU�STRA T ________________•-__-_____ Owner's Name ---/W, ---------------------------------- --- ------------------- Phbfie + 1 � �J Address _ `` t - -0 ---- --------- -------- -- city y Contractor's Name ___ /- ---------__.L �; i-- =__________________-_________._.______License #I7 -- Phone __ Installation will serve: ResidenceoApartment House❑ Commercial ❑Trailer Court Motel ❑Other -------------------------------------------- i 1-1 Number of living units:__-- ------ Number of bedrooms ----1------Garbage Grinder /rte-0-__ Lot Size 16V___1r ________________ Water Supply: Public System and name -------------------------------------------------------------------•------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loan--PR(� Hardpan ❑ Adobe ❑ Fill Material _________ If yes,type ___________________._______ pv� (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 [ ] SEPTIC TANK] Size_-111X5_ (5'x_____________________ Liquid Depth ____ - -.-__________---- Capacity� 4W_ Typ%9.'4° %_i__ Material � C No. Compartments o�_ - ----------------- LV Distance to nearest: Well _`'`� ______________Foundation __/Q--E__-_____ Prop. Line _. �_...__•._____ ��► LEACHING LINE No. of Lines _/------------------ Length of each line--- Total Length _/�_ ______________ 'D' Box /� ,1.1�!?___ Type Filter Material /�OC�____Depth Filter Material __,�9_ ._____________________________ Distance to nearest: Well ' -- -__ Foundation __/®_____________ Property Line ._C�.__.___.__.__._. SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ----- ---------------------- Rock Filled Yes '❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well _____________________________________Foundation -------------------- Prop. Line _____--_----------__.. REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------- ---------------------------- Disposal Fie (Specify Requirements) ----------- ---------------------------------------------------------------------- - ------------------- (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 su ct to kman's Compensation laws of California." Signed ------ --- ----------- - ------ - ------------------------------------------------------ Owner --- ----------- Title ----------__--------------------------------------------------------- (If ter han owner) 1A a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE 7'a- ' BUILDING PERMIT ISSUED ----------------------------------------------------- -----------------------------------------DATE ---------------------------------------•--- ADDITIONALCOMMENTS ------------------------------------------------ ----------------------------------- ------------------- ------------- --------=--------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- --- ------------------------------------------------------- - ---- -------- ---- - ---- ------------------- � �Final Inspection b -- --------- -------- - ------------------Date --------------------------------------- SAN - l- ---- - -------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M