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iM FOR BICE USE: - ' , APPLICATION FOR SANITATION PERMIT -------------- - ------ ------------ (Complete in Triplicate) i Permit No: i .. .�.. �. � bate Issued --�---�-=-.�3 3 -- ---•-- : ---- jjt This Permit Expires 1 Year From Date Issued I 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 exi,sting Rules and Regulations. I , '] - -- -------------------- - --- CENSUS TRACT --------------------------JOB ADDRESS/LOCATION ./ L_ ----- ------- - --- Owner's N77am�p -�'',- -�U-Q- --,--,-f-�.y��_C�P��- - I�.l�'�----------------------------------------�--Phone ------------------------------------ Address r�-�.---/------=(/� _ 1't ` 1? --------------------------------------- City ��61i°,5 - � -----------------•- Contractor's Name ---�'I r i�W {, `�-- p- --- ---f------- License # Phone i s il. E Installation will serve: Residence DCApartment House❑ Commercial ❑Trailer Court !❑ I Motel F-1 Other ---------------- '`---------------------- k Number of living units:_______ __ Number of bedrooms ________Garbage Grinder ------------- Lot Size ___________________________________________ Water Supply: Public System and name ----------------------------------------------------------------------- ----------------------------------Privatel?r Character of soil to a depth of 3 feet: Sand' Silt❑ Gay ❑ Peat❑ Sandy Loam •❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 3 PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size_______________________________________ _______ Liquid Depth --------________-____,___. Capacity ------------------- Type ------------- ------ terial------------------ N8. Compartments ----------------.:.... Distdnce to nearest: Well -----________________ ____________Foundati ----------________.-_ Prop. Line _________-______...._. Q LEACHING LINE [ ] No. of Lines ------------------------ Length of each line___________ _____.________!Total Length _____._.__-_-_______--___. r- 'D' Box -'+--------- Type Filter Material ------ ------------Dept Filter Material ----------- -------_---------------------_.. 7 Distance Ito nearest: Well ______________ ________ Foundation ----_----------__---!E_ Property Line -_____-._._-__ ________ SEEPAGE PIT [ ] Depth ___`_____ _________ Diameter -- ------------- Number . ____.__.______._______ _ Rock Fil,'d,"l,Yes ❑ No Water Table Depth ---- ------------ --------------------------- - ck Size ------------------- t ----------------- -» Distance to nearest: Well ______ _____________________________- -Foundation _______.__�__________ Prop. Line ..--____..________-.__ REPAIR/ADDITION(Prev. Sanitation Permit# --------- __________________---___ _-Date -----------------------�__________-) Septic Tank (Specify Requireme'ts) -------- --------------------------------------------------------------------------- ----I--- ------------------------- Disposal Field (S i' Requirements) �` ----------------------------- x, f-' '------- -- --- ... i (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 fallowing: Ilpl "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner ` as to become subject to War an's Compensation laws of California." Signed __ _ .__ ----- ---- - - -------- - --------------------------------- Owner ------- - ------------ --- BY Title ------------------------ --------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ----- -----9;4i4- ------------------------- -- ---------------------------------- DATE `fir ` ----------------- ------- - BUILDING PERMIT ISSUED -- --------------- - ------ --DATE ---- -------------------------------------- ADDITIONAL COMMENTS ----------- ------------- --=[----------------------- E --------------- ------- ---------------------------------------------------- -- - ---------- -- -------------------- ------ - I ..---------------------------=------- --------------------------------------------------------- I Final Inspection by: ------ l f -------.Date ......15-- ------------------ c SAN JOAQUIN LOCAL HEALTH DISTRICT f E. H. 9 1-'68 Rev. 5M ��