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• I:oR OFFICE usE: { APPLICATION FOR SANITATION PERMIT -------- ---- . 1 - - ._ ' ! � (Complete in Triplicate) ,Permit No. - -------------------------- ----'------------- Date Issued ---0 -/ _______________________________..___ --- ?__.__________ This Permit Expires 1 Year From Date Issued -7 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 County Ordinance No. 549 and existing Rules and Regulations. ! � 17d JOB ADDRESS/LOCATION __. ---------CENSUS TRACT/�_ Owner's NamePhone01'�_...- -- ------ ---- -------------= --- - ----------- City- --------------------------------------------- Contractor'sF Name -__. _ _ _ _ _ ____ v4wd�____________-License # Phone Installation will serve: , ResidenueRy�(partment House-❑-Commercial,❑Trailer Court 'E] i Motel ❑Other --------------------------------------- {--- Number of living units:----- Number offbb�edrooms_-•---Garbage Grinder ------------ Lot Size ._________________ _______________________. System and nameC.� �---------------------------------------------------------------------Private Water Supply: Public _ Character of soil to a depth of 3 feet:f- Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ sY, .r Li Hardpan ❑ Adobe,�Fill Material ------------- If yes,type'___________________________� (Plot plan, s_ owing_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,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size_ Liquid Depth Capacity ----- Type Material__�C-_____ No. Compartments __ _____________ Distance to nearest: Well ____________________________________Foundation s`_______ Prop. Line - --________ 1 LEACHING LINE [ ] No, oALinesy-____ _____________ Length of each line - ------------ Total Length ___,,.Or--gip__'__._.-_ �. 'D' Box i___,__._:Type Filter Material -��4__.____Depth Filter Material __._ ............. -.._..______ Distance to nearest: Well ------------------------ Foundation -7.0 Property Line ---2477____--_----- SEEPAGE PIT [ ] Depth --------- Diameter . -- -------- Number -----OZ---------------- Rock Filled Yes No e Water TableDepfih -- Rock Size L------------------- Distance tc nearest: Well ----------------------------------------Foundation ------------ ------ Prop. Line -------------•-•.•_-.- REPAIR ADDITION Prev. Sanitation Permit S# -------------------------------------------- Date ---------.------------------------- } 1 ' ,y Septic Tank (Specify Requirements) ------------------•----------•--------------------- - ------------------- --------------- ------------------------------ DisposalField (Specify Requirlents) --------------------------- -------------------------------------------------------r------------------------------------------------- ------------------------------------------------ ------------------------------------------------------------------------------------------------------- ------------------------I--------------•--------- 1' 1� --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) I I hereby certify that I have prepaE6d-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 1W such manner as to become subject to Workman's Compensation laws of California." - Si ne g ------------------------------------------------------------------- Owner -A- BY R Title _ iia ------------------- - a- -------- -------------- (If other than owner) FOR DEPARTMENT USE ONLY- - - APPLICATION ACCEPTED BY ---7--c-d-----A/D._r _Y ------ DATE /�� BUILDING PERMIT ISSUED --------------------------------------------------- -----DATE ---------------- ---------------------------------------------- - -------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- - -------------------- ---------------- - -- ----- -------------------------- ------------------- - -- -- - - ------- Final Inspection b _____�.. _ _ _________ _ �----� __ --------- -- p Y -.' --- ---------------- ------- ---- --- Date s7 SAN JOA IN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M