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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. . ----------------- -------------------- ----------- (Complete in Triplicate) ' Date Issued - ------- --------- -------------- - I This Permit Expires ! Year From Date issued f Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work s: described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOS ADDRESS/LO 10N _-_ -- j CENSUS TRACT ---- -•----•-•---. � Owner's Name. ---- -- - ------ - ----------- -- - ---- G - ----------------------- --------------- Address 11--� '" --- ------,-------- Cit y - --- O Contractor's Name .""--- -------------------License # --/- - -phone .___----------- -i Installation will serve: Residence)f Apartment House❑ Commercial ❑Trailer Court ❑ 1� Motel F-1Other -------------------------------------------- Number of living units:_--_I------ Number of bedrooms --,A-----Garbage Grinder _____.--____ Lot Size ----- -- { [; Private Water Supply: Public System and name ---------------------------------•-------------•----- --------- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat E] Sandy LoamA Clay Loam ❑ 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.) V NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) t SieLiquid Depth - -----------------•-.----- PACKAGE TREATMENT [ ] SEPTIC TANK --- ------------------------ g1 No. Compartments -- V ' _. ----------------••-- Capacity E ---------- Type ------'------------- Foundat- 4 ,.. : . . ..- ,. Material"---- Distance to nearest: Well ------------ -- --- - _ an ---------------------- Prop. Line ---------•------------ t i Total Length ---------------------------- ------- Length[ ] ------- Length of.each line-- --------------- -- No. of Lines - 9 -- Depth Filter Material ____.--_____ -----------••------ 'D' Box --- ---- Type .Filter Materia!' ------ --------- -- t . Distance to nearest: We ---"-"------------ ----- Foundation --------------- Property Line -----••--------• ' Diameter Number -------- ------------------- Rock Filled Yes ❑ No SEEPAGE PIT [ l Depth i t --------- Water Table Depth Rock Size -------------------------------- . ---------------- - .1 , ,: -------'`"----Foundation ----- Prop. Line __.. --- --- Distance to nearest: Well ______-_'----=--------- -. V REPAIR/ADDITION(Prev. Sanitation -_ Date _____�___________________________] n Permit# ------ i J Septic Tank (Specify Requirements) __-____- ------------ ----------- y Requirements __ _ -------- ` Di o al Fi (5pecif Re u+r "" -----" ""-"" - - - -------- - ---- �— ---------- - - 1 - - -- --------- ------ Q------- - ------ -- -- J ------- ' -------------------- -------------------------- ---------=--------- ------------------------------------------------------------------------------------------------------ 1 � (Draw existing and required addition on reverse side) I hereby certify that l 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 t as to become subject to Workmans.Workmanmpensation laws of California." Signed 1------- --=----- === s= - -----------_------ ----- LA n -„ ----------------------------------------- Y Title [If other than owner} /t , �7 . .: I a FOR DEPARTMENT USE ONLY DATE._ s 7 L` APPLICATION ACCEPTED BY ---___-- �__ ��u—------- DATE ------------------------------------- BUILDING PERMIT ISSUED ----------------------- ADDITIONAL COMMENTS ------------ --------- ----------------- ----------------- - -- ------------------------------------------------------------------ ------------- ------------------------------------------------ - - ----- ------- _ -------------- Inspection by: _-- --- ------------------------------------------------- Final 5AN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M