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FOR OFFICE USE: I' � APPLICATION FOR SANITATION PERMIT l �s7 (Complete in Triplicate) Permit No_ ______________ ____ --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued 73 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 Cou y Ordina ce No. 49 and existing Rules and Regulations: JOB ADDRESS/LOCATI r -------------CENSUS TRACT -5�6---------`---- Owner's Name ---- f' - - - - - - ----------- -------------- --- ------ ------ hone ---------------------------------•- Address ------ -�� -�- --`------ ----- 4 -- ------. City ---- ------------------------------------------------- Contractor's Name ----- ------ - --- -------------- :__.__.License # .- Phone ------------------------------- Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 'E] f Motel ❑ Other --- ------------------------ Number of living units:------!__--- Number of bedrooms __`�Garbage Grinder ------------ Lot Size _.__--_-_`___________________________________ Water Supply: Public System and name ---------------------------------- -------------------------------------------------- -----------------------Private M---- p ��Aclobe-E] - y ❑ Clay Loam ❑Character of soil to a de th of 3 feet: Sand' t Cla Peat Sand Loamp ❑ Y ❑ ❑ YHard an Fill Material ------------ If es,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,) PACKAGE TREATMENT [ I SEPTIC TANK f ] Size---------,r------------------------------ Liquid Depth ---_---------------------- Capacity -------------------- Type -------------------- Material---------------------- No.'! Compartments -----------------=•--- ` Distance to nearest: Well ____________________________________Foundation -------------_--------- Prop. 'Line ---------------------- LEACHING _--________:_LEACHING LINE [ ] No. of Lines ------------------------ Length of'each line---------------------------- Total Length' 'D' Box ------------ Type Filter Material ------------------DepthL.Filter Material _-.------------------------------•---------- Distance to nearest: Well ________________ _ Foundation ------------------------ Property Line --------------------- SEEPAGE _____.__________._SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------- ----------- Filled Yes ❑ No Water Table Depth ------------------------------------------------ F ---------------------------Foundation -------------` Distance to nearest: Well ------------ Roc Size ---------------' i '� Prop. Line - r--•----- ----------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------------k----) Septic Tank (Specify Requirements) ----------------- ---------- ------- ;------------- -------------- -- - ---------- sal Field (Specify Requirements) --------- -- ---- "-- - --- -- --- - --- ----- -- --l - - - ------------- ------- ° ---- -- a -- a - - --- --8 - (Draw existing and required a� d on never s 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 i as to become subject to Workman's Compensation laws of California." Signed Owner ----------------------------------- BY --------- ---- -------------- � � Title (If other than owner) OR DEPARTMENT USE ONLY .F APPLICATION ACCEPTED BY -----------------------------------------,---------------- DATE --- --'.- 1`73�- ---------------- BUILDING PERMIT `ISSUED ------------------------------------------------------------------------------------------- --------------DATE -------------------------------------- r ADDITIONALCOMMENTS ---------------------------------------------------------------- -•--------------------------------------------------------------------------------------------- ;I ------------------ -------------------------------------- - t - _ --------- ate _ :. Final Inspection by: ------ _ D `� ��' _ _- --- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ,