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OR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- - ------------- -----W- --- Permit No. (Complete in Triplicate) I ----------------- -------------------------------- /3 -7 Date Issued _____ ___________ _ --------------- This Permit Exp ires 1 Year From Date Issued ra. Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins#all the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: Jr JOB ADDRESS/LOC ION / ------(e—V--- -a� Z--------- l_)d------------------------------CENSUS TRACT -------------------------- Owner's Name - _.�- -{�'5------ --- L 11, ------------------------------- ---- ----- ------Phone - -----------------•--------------- Address _ Q --- -----�_-2-6------ - - -------------------------------------------- City/ - Contractor's Name -- =--•--(� r's- �l' --------------------------=-------.License #oZ- tl: _ Phonac _r _ Installation will serve: Residence ❑ Apartment House�X Commercial ❑Trailer Court l❑ Motel ❑ Other -----------------------------------•-------- Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ------------ 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 F-1 Fill Material ------------ If yes, type ---------------------------- (Plot -_-____-.-_______-- -_-___(PIot 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------------•------------------------------ --- Liquid Depth __------------------,----- � t Capacity ----------------- Type ------------- ------ Material--------- ----------- o. Compartments r�r i Distance to nearest: Well ____________ -----------------------Foundation __ ------------------- Prop. Line -----.--_______------- W LEACHING LINE [ J No. of Lines ------------------------ Len h of each line----------------- ----:_ Tota! Length --------------------_------- t'D' Box --___-. Type Filter Mat ial _- ________________Depth Filt Material --------------------.--------------,___-----. Distance to nearest: Well _- _ -_--_____-__- Foundation -------- --------------- Property Line -____._________-__---__�` SEEPAGE PIT [ ] Depth } Diameter ___-____ )tock Filled Yes No Number ---------- ---- - ❑ Water Table Depth -------Rock Si a -------------------------------- --------------- -------------- Distance to nearest: Well ------ -------- - -- Found tion -------------------- Prop. Line --------------•------- - - ------------ REPAIRJADDITION(Prev. Sanitation,Permit r# ------------ - ---------------------------- Date _ ___-________--__--------.._____) Septic Tank (Specify Requirements) ------ --------------- ------------------------------------------------------------------------- Disp al Feld {Specify Rirene t ) ,y - ------ --- - ---a ----- --s -------- ----------- -- ----- -- - - - (Draw existing and required addition on reverse side) I hereby certify that 1 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. Horne 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 Compensation laws of California." l Signed --------- ------- ------------ ----------- --•- Owner Title --------------------- --- (If other than owner)' I " FOR DEPARTMENT USE ONLY PPLICATION ACCEPTED BY _-- t __------. DATE -------'� -- •------------------- --- - ----- - - -------------------------------------------------------- -_ BUILDING PERMIT ISSUED ----- = --------------------------------------------------------=--------------DATE ----- ------------------------------------- ------------- - ADDITIONAL COMMENTS ---------- -' - ----------------- --------------------------- --------------------------------------------- --------------------------- •---------------------.- --------- -------------------- ' - ----------------------------------------------------------------------------------------------- ----- ' ------------------------------------------------------------ --------- -------------------------------------------- - -- ------- Final Inspection by: _---- - Date .-_- '� ".---�/-.- ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M