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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------- Permit No,. .-73—/O / II (Complete in Triplicate) ..........I---------------------------------------------- i ________-_____----- This Permit Expires 1 Year From Date Issued Date Issued ��f ._..... ---------------------------------- Application is hereby made to t> a San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in corripliiaance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ------ '� _ /--/ -_--,L�tRc �-----------------------------------------------CENSUS TRACT ------- Owner's Name ) ---------------- ------ ------Phone_��-is"7��--- 1 f 1 ' �--`-`-----(7---- f.7_-y�------------------ City 1-'.!-f C✓_L_/ -Cl ----------------------------------------- ---------------- Address �,— f Contractor's Name ---- `' -------------- /--'P-----=---------------=--------License 9�0_._-__ Phone �_`G._--__'_'___! k Installation will serve: !Residence [❑ Apartment House❑ Commercial :❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units_____________ Number of bedrooms ____________Garbage Grinder ------------ Lot Size Water Supply: Public System and name ---------------------------------------------------- ----------------------------------------------------------Private R \ Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ 4 iHardpan ❑ 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.) i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size-------------------- ---------------- ------ iquid Depth --------------------,----- I Capacity ------ ------- ----- Type -------------------- Materia ---------------------- o. Compartments Distance to nearest: Well ------------------------------- ___Foundation --------------------- Prop. Line _____._-__---__-_____. LEACHING LINE [ ] No. of Lines _______________________ Length of eac line ------------- ------ ----- Total Length ---------------- ____________ 'D' Box,I----------- Type Filter Material ______ ____________Depth ilter Material ______________ Distance to nearest: Well ____________________ __ Foundation __._.__________-_____ Property Line ------------------- SEEPAGE PIT [ ] Depth ---------------- _- Diameter ------- -------- Number --------------------- Rock Filled Yes ❑ No i❑ y Water Table Depth --- ----------------- ------------------------- ock Size -------------------------------- t Distance to nearest: Well ---------- ___________________________ _Foundation --------_ ---------- Prop. Line -------- ...... I REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ------------------ -------- _ Date ----_________________________._--) 11 ISeptic Tank (Specify Requirements) ------------------------ ---------------------------------------------------------------------------------------•.-------------------------•- Disposal eld (Specify Requirements) -------- ------------------ ------------- --- L ------------------------------------------- ad --------------------------------------�- -- -------------------=---------------------------------- ---------------- ---------------------------------------------- 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 following: "I 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 mpensation laws of California." Signed ----------- -- -------------------- ---- ------------------- Owner BY --------�� Title ----------- --------------------- ---------. -- ------------------ ---- (if other than ownei) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----�1----- ---- ------------------------------------------------------ DATE -- -----D-_-z r 3 BUILDING PERMIT ISSUED --------LI-------- -------DATE -------------------------------- ADDITIONAL COMMENTS -------- --------------------------------------------------- r ------------------- -------------- -------- ------ - -- Final Inspection b l/----- ----------------------------------------------- -- ------ -----------Date ----f O_:773 - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M _ .