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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r � ............. .....................................-.----- Permit No. ................ (Complete In Triplicate) r .........................................._...._ Date Issued ��.............. 4 ................ ........... ........-_-- This Permit Expires t Your from Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal( the work herein described. This application is Mail • compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ... .. -... ........................................CENSUS TRACT .................... Owner's Name --- ... Q.�i! S. ......... ...Phone . Zs -. . .� Address ._. ....-........._-----.. , �.1__.��---.�.....!�i9:�h_rxop_..�'�...........................�-----....... City .. � lrP.......... ..��----- Contractor's Name _..:_- � '.................... ........License �ll. -- Phone $'m ice••-•- -- .....----••- Installation will serve: Residence 0 Apartment House❑ Commercial OTrailer Court 0 Motel ❑Other .' Number of living units:..'./ Number of bedrooms Garbage Grinder ............ Lot Size .....-----.-• ••--••••••---•••-- Water Supply: Public System and name ------------•-•...:........................ .............._--...........................................Private gr Character of soil to a depth of 3 feet: Sand'❑ Silt.❑ Clay ❑ Peat❑ Sandy Loam fl Clay Warn ❑ I Hardpan p Adobe❑ Fill Material ............ If yes,type ............... ............ 4. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer.is available within 200 feet,) PACKAGE TREATMENT [ } SEPTIC TANK; } Size--------------------------•-----...-•---. ..... Liquid Depth .........-................ VP Capacity -------------------- Type --/the --------- Moteri --------••-•-------- No. Compartments ....................... � Distance to nearest: Well ------ ................ •----Foundatio __ ......... Prop. Line _t.........----...... °D LEACHING LINE [ ) No. of Lines ------------------------ h of ea line.__----- Total Length ..........._._..........._--M 'D' Box ' .... Type Filter Mal ...Dept Filter MaterialDistance to nearest: Well ------ -------- Foundation _.....-.__.......---.... property line ...-......._........SEEPAGE PIT O Depth -------------------- Diamete ---------- Number ----------------.---_._..--- Rock Filled Yes ❑ isowater Table Depth ..._... - . --•-•-•--•.... . ock Size __......-... :.. I Distance to nearest: Well ------- --------------•_--- -__--Foundation ----.......--------- Prop. Line _............_.......r'p REPAIR/ADDITION(Prey. Sanitation Permit�# ---•-------•-- --•---------------•--- Date -----:-.-.-_-----------._..-...._.I It• Septic Tank (Specify Requirements) ..-•----------•--- ..................................... •-•- ............-•.................I--........................... Disposal Field (Specify Require ents) ._.__� -._ --. f .. ...........0.. _�1 -•.........--•--•-------__---._...._...._.._..._...... ." ......................... ' -------------------------------------------- -----------------------------------•-----.-------------------------------------------- ................................-...... t (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 l County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Hatne 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' compensation laws California." Signed --- ----•--- Owner Y - -•- ------ ---- •-- Title _... . -------•---------- ---------- ----- If other than owner) _ FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY - ----- --- --------------------.-•--•_----- DATE -- ..., `� ..� ------------ - BUILDINGPERMIT ISSUED --- ---- ---- --•-----------------•-• --------------•--•-----_-•-- •---•--...._.---- ....-DATE . .------- ------•---------------- ADDITIONAL COMMENTS --------- ------ ---••-----• --- --• ....._.. ------ --•-.....__..._..._..- j ------•--•------•- - --------------------------------•------..- --------------•- ----------- ---------------- ---------------------- ---------------•------------------------------------------------- --------------------.-.-......_...�Iv -- ---- Final Inspection by: _ .._....Date _....._ ......°�.` ............. EH J_3 2h 1-66 . 5�i � SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M I