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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- - Permit No. (Complete in Triplicate) ----------------------------------------------------------- Date Issued / This Permit Expires 1 Year From Date Issued 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: JOB ADDRESS/LOCATION ._,�' --- - - - - ------—----------------------- CENSUS TRACT QQ Owner's Name ----- -------Phone ,6� �2R , --------- hone (�-� City - - f� ! Address _�--�6 -�------/��,-.U1-E��/ -- --- ---------- .• � ---•------•-----•-• ��-----•---�9�� •�/ ------------------------------License #-9- " Phone �� - -�� Contractor's Name --.� � �- -- ' Installation will serve: w Residence [4 Apartment House'E] Commercial ❑Trailer Court l❑ i Motel ❑ Other -------------------------------------------- Number of living units:----__ --- Number of bedrooms .--?---.Garbage Grinder ------------ Lot Size ----___------------------------------------ Water Supply: Public System'and name --------------- ----- ----=`--------------- ---- --------------------------------------Privateer Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ U Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------_---------.- (Plot plan, showing size of:,, location of system in relation to wells-, buildings, etc. must be placed on reverse side.) �i NEW INSTALLATION: (NoI septic tank or seepage pit permitted if public s er is available within 200 feet,) a PACKAGE TREATMENT [ I r SEPTIC TANK.( ] Size------------------ ---------------------------- Liqui epth ---------------•---------- Capacity --------- Ca acitY ------------------- No. mpartments ---------------------- ------ ------------ TYP Materi --- Distance -------------- to nearest: Well ---------------- ------Foundation ----___ .- --_------ Prop. Line -------.-----_-------- 'LEACHING LINE [ j No..of Lines ------------------------ Length of ea line-------------------- ------ Total Length ------------------ --------- 'D' Box ------------ Type Filter Material ----- --------------Depth Fi r Material ---_--------------------------------------- --- Foundation -_- - Property -- E Distance to nearest: Well ------------------- - -----___------ --- Pro er Line __---.--------:..---- SEEPAGE PIT [ ] Depth -------------------- Diameter ------ --------- Number _-- ---------------------- Rock Filled Yes ❑ No i❑ , :;, Water Table Depth -------------------- -- ---/---"'-�----Ro Size ---- ----- ------------------ Distance to nearest: Well -------- -----/ ation -_-__-------------- Prop. Line ---------------------- +REPAIR/ADDITION(Prev. Sanitation Permit# ------------ -- ---------------- -------- ate ------..------------•----------. ) Septic Tank (Specify Requirements) ------------- -------- --------- "------------------- , Disposal Feld (Specify Require ents) -- / ---'--•� --'/ - gip° _,,645,4 �II ------------------------------------------- ------------- ---- ------------ -- ------------------------------------------------------------- f (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. Horne 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 Y as to become subject to Wor man's Compensation laws of California." Signed -------- - -------------------------------- ---------------------- Owner BY .- . l --------------------- Title ------------ ---------------- -- ------------------------- -------------- F (If other than owner) - FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY -------- ---- ---- -----------------------------------------------------------------------I DATE ----IV- '-'-/--•-}--'3------------ BUILDING PERMIT ISSUED-'---------------------------------- ----------DATE ------------------------------------------- ADDITIONAL COMMENTS ;:------------------------ - - - --- - ------------------------------ ------- ----------- --------------------------------------------- ------------------------------------------- ------------------------------------------------------- _ te--------- -�--/- _- ----------------- Final Inspection by: -----------------------------�� -- _Date --. 3 SAN JOAQUIN LOCAL HEALTH DISTRICT G 3 E. H. 9 1-'68 Rev. 5M "