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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) /� -------------------- -- ------ Permit No. _tel._-. �: ---------- --------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued /`:_ _2 61 -- .-_ _ _ ---------- - ------------------------------------ - 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 Regulotions: JOB ADDRESS/LOCATI N �LQ_ a�--�!_'_ - -'- ___�------------------------------CENSUS TRACT -------------------------- Owner's Name - ----- Phone f� �' /� Address � 7 5zz�¢.--`ae9 `_ CitY "- `t s ---------------------•-------------•--- Contractor's Name -------- r License Phone k Installation will serve: Residence (Apartment House❑ Commercial :❑Trailer Court 0 Motel ❑Other - ------------------------------------- Number of living units:------,_---- Number of bedrooms_______Garbage Grinder --- -___ Lot Size ___ - i___ _____ ____ ---------- 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'❑ Fill Material ------------ if yes, type ---------------------------- (Plot _______________________ __-(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 seep ge pit permitted if puplic sewer is available within 200 feet,) PACKAGE .TREATMENT [ ] SEPTIC TANK'[ Size_��_sx_ _-A-__�_�__------------ Liquid Dep h - ___�____________. 1 Capacity _1114.4-- Type -��- Material_4:P_4-j&0 _------ No. Compartments -- ---...--.---- Distance.to neares : Well --_---------C- I----- ---------Foundation -__J_Q '---------- Prop..Line ---- -------._------ LEACHING LINT= [ No,.'of. Lines ._ _ Len th of each line__ _ _ ©_ ---- Total Len the � 1,[_, =T pe Filter Material _Depth Filter Material f� D' Box {- —Type ------ - Distance to nearest: Well ____=`_"_ ___________I Foundation t*Q_______________ Property Line -----____________-:-___ SEEPAGE PIT [ ] Depth ------------ ---- Diameter -------------- Number ---- Rock Filled Yes ❑ No I❑ IV I r Water Table D pth _ ,-- - --------------------Rock Size - ---------- t, Distance to nearest:-Well --------------------------..........Foundation --------- ----_ Prop.,linei�----____-____________ REPAIR/ADDITION(Prev. Sanitation Permit=# _________________________________----------- Septic Tank (Specify Requirements) -----------------------------------------a-------------------------- ------------------------ --------------- ,---------------------- Disposal Field (Specify Requirements) ______________________ ---------- ------------------------------------------------------ ------------------------- ------------------------------------------------------- -`- ------ ------------------------------------------------------ ------ ---------------------- ---------- ----------------------------- ------------------ -------- ----- ------------------------ r{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 J,,,i4h- 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 4 "I certify that in the performance of the work for which this permit is issued, I shall not employ any per ion in such manner as to becouSh subject to Workman's Compensation laws of California." Signed ----------- ---- ------------------ --------------------- Owner BY ---------------------- Titlen d (If other than owner) FOR .DEPARTMENT, USE ONLY APPLICATION ACCEPTED BY ------------- I --------------------- ------ DATE -- _ . - ------------------ BUILDING PERMIT ISSUED --------------------------------------------- ---DATE ------------------------------------------- ----------ADDITIONAL COMMENTS ----------------------------------------------- --------------------------- ------------------------------------------------------------------- - ------------------------------------ ----------- ----------------------------- --- ------ ---------------------------------------------- -----------------------_----------------------------- ---- _ -------------------------------------------- - Final Inspection by: --- ------- -------Date " ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M