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t FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------- ------------- ------ - Permit No. (Complete in Triplicate) ----------------,------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued Q,? Application is hereby made to theSan Joaquin Local Health District for a per to construct and install the work herein described. This application is m de in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . k �u-G a - CENSUS TRACT ------------- ---- Owner's Name ---��Pry�A / L -w` ---------------------------------- - Phone Address -------------------- -- ------------ City ------------------------------- Contractor's Name t ---------- -------.License # a2 sY/7. .- Phone -------------- Installation - ----- Installation will serve: Residence [] Apartment us ❑ Commercial ❑Trailer Court l❑ fMotel ❑ Other - ------------------------- Number -----------------------Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ------ ---------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet.' ISand'❑ Silt fl Clay Peat❑ Sandy.Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe '❑ Fill Material ------------ If yds, type --------- ------------------ O (Plot plan, showing size of lot, location of system'in relation to wells, buildings, etc. must be placed on reverse side.) �l NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK - - Size S XS/r-—--------- --------- Liquid Depth -----y------------ --- Capacity3 -------------- Typ�/Q- - Material No. Compartments ------ ............... I Distance to nearest: Well - `O ------------------------Foundation .. a-----_-_---_ Prop. Line _-_� _.-......__ F i line-,/40 ------ Total Length �dQ............. - LEACHING LINE No. of Lines ---- -- ------- -i =+Length of each line_ 'D' Box .-�-.--- Type Filter Material S%- Q_ '-_Depth Filter Material ------/----------------------------- - i , Distance to nearest: Well __8S°----- __-_ Foundation --- --------------- Property Line -- a-------------- SEEPAGE PIT [ ] Depth --_- ---------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ i Water Table Depth --------------------------------------- ..Rock Size --------------------------- I Distance to nearest: Well ----------------------------------------Foundation :--------:----.._-. Prop. Line -----.--.__-____---_-- k REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------...----------- } ' SepticTank (Specify Requirements) ------------------------------------- --------------------------------- --------------.--------------------------- Disposal Field (Specify Requirements) - -------------------------------------------------------------------------------------------------------------------------------------� ------- - -------------- -----------------------------------------------------------------------------------------------------------------------------------------------------' ----------------------------------------------------- ----------------- ---------- ---------------------------------------------------------------------------------------- (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 per lit is issued, I shall not employ any person in such manner s Compensation laws of California." as to U l Signed become subject to W man------------- --,� _--- Owner BY ------------------------------------ -- - - ------------ --------- Title ----- ------ ---- (If other than owned. I I FOR DEPARTMENT USE ONLY G. k APPLICATION ACCEPTED BY ---- ' -------------------------, DATE -- _-._ -.` - - ------____-- /_ 1�---------------------- BUILDING PERMIT ISSUED �' ---------------------- - =' { -- ----- ATE ------ - - - f ADDITIONAL COMMENTS -----5 1u-x_21----- - � `Sf� �--�` - " '-......P - _ l ' , _ }------------------------------------------ --------- t ----1-------`------- ---------_.-------_--------------------------------------------- -j ) ---'------- ---- - -- --------- --------- ' --- 1 Date .- _ `j�-- Final Inspection by: . - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M