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FOR OFFICE user: APPLICATION FOR SANITATION PERMIT - ------------------- - - Permit No. (Complete in Triplicate) ------------ -------------------------------------- Date Issued --------------------------- ----------------------------- This Permit Expires 1 Year from Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 _/ _ - - ,--- .--- SLE � 1 '�7---- /�-,�--------CENSUS TRACT ---s----�------------- Owner's Name _.._ < __. Phone -------------------------------- Owner's Name - r u Address --- d------------------------`-------------------------------------------- City -A'a-d/-------------•-------------------f----'-------------. -- Contractor's Name ---- --= �f/u- --------------------------------License #/i-�1o�'� ��_ Phone �PkO�-2 14. Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ----------------- - ------------------------ Number of living units:----(_----- Number of bedrooms J_______Garbage Grinder AIR--- Lot Size "V-� 6q,,, --` ------- Water Supply: Public System and name - ---------------------------------------------------------------------------------------- ---------Private, Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay loam ❑ Hardpan Adobe ❑ Fill Material ___________ If yes,type _____________________, p (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) q� 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: Well _______________________ Foundation _T--------------------- Property Line ________-.__..--__._.__. SEEPAGE PIT [ ] Depth -------------------- Diameter ____ ----------- Number --_`_.,_-------____.__ __-_Rock Filled Yes F] No Ci Water Table Depth --------------------------------------Rock Size -------- ' :. Distance to nearest: Well ----------------------------------------Foundation ------ ------------ Prop. Line ----------------- REPAIR/ADDITION(Prev. Sanitation'Permit# ---------------------------------------------Date-_=A....__---.-.=--_-------------} Septic Tank (Specify Requirements) ------------------------- ------------------ --------- ------------ ---------------------------- -------------------------------- Disposal Field (Specify Requirements) ___ � ___, � ---- /a� - '--- _-- -----------. �' � ` -- r - ----- --------------------------------------------------- - -------------------------------- -------- - -------------------------------------------------- ----------------------------------,------- (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 ofithe 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 Y �,7�� BYTitle - "_ - �~------------------ -------------- her than owner) EOR DEPARTMENT USE ONLY APPLICATION' ACCEPTED BY -------------------------------------------------------------- DATE --- ?`3------------------- BUILDING PERMIT ISSUED ------------ -------- ----------------------------------------- -------DATE --- --------- ----- - -- ------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- - - --------- - - - - Final inspection by: - ------------------------------- -------------Date, ._ --"�'► SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M