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-!FOR OFFICE USE: x APPLICATION FOR SANITATION PERMIT --------------------------------------- ------------------ ----------------------------- - r (Complete in Triplicate) Permit No. This Permit Expires ] Year From Date Issued 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: t JOB ADDRESS/LOCATION �� `" (aG.is_ " Owner's Name �/� --•- --------�� -------- ---- --CENSUS TRACT s� ---- -- -- - ------1-�-�-��-erg..------ - � :------------ ------- --------------- ------ -- --- -------------- s - - - - _Phone --------------- Address -c� Q_U �- �'{----- City X&v_ ._(Z0 7 Contractor's Name .._. -- -----------License # �VIV 7439 - Phone Installation will serve: Residence ❑Apartment House❑ Commercial '❑Trailer Court 4 Motel ❑'Other Number of living units:_-___ ----- Number of bedrooms _____Garbage Grinder ._____-__- Lot Size _C� �&1 f _- _- ? �• ' Water Supply. Public Sys em and name _.-•_---_-•-_ _ e F -------------------------------------- -- ------Private R7 Character of soil to a depth of 3 feet: Sand's Silt❑ Clay ❑ Peat❑ Sandy Loam '❑ Clay Loam 'E- Hardpan ❑Hardpan ❑ Adobe ❑ Fill Material ------------- If yes, type ---------------------------- (Plot -------- -----_ ___(Plot plan, showing size of lot, location of sys m in relation to wells, buildings, .e . must be placed on reverse side.) W NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is a ailable within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size---------------------------------- ------------ Liquid Depth ------ ------------------- Capacity -- ----------------- YPe -------------------- Material-------- ------ ------ No. Compartments, ' Distance to nearest: ell ------------------------------------Foundati n _________________ Prop. Line ----------••-=-------- LEACHING LINE [ ] No. of Lines ---------- Length of each line------------- -------- --• .Total Length ---------------------------- 'D' Box __ ,_..--_- Type Filter.Material ___________________Depth filter Material --- _- Distance toi nearest: ell __.-______------------- Foundation _.__ _ .___---___:- Property Line _____-____-_ SEEPAGE PIT [ ] Depth :__ -! ---- ------- iometer -----_ Number ------- -----------------------Rock Filled Yes 0 No jQ e Depth Rock ize --------------- -ter Tabl ---------------------------------- REPAIR ADDITIONSanitation Distance to 'nearest: Well ---------------------------------------Foun ation ---------------< _ i / (Prev.f Permit � Pro Line ___.______________••• i ------ ----------------.------------------- Date . ----------- µ} ` a - - J. Septic Tank (Specify Requirements); _______ _________"_.:•il Disp sal Field (Specify Requirements) i :A} k ------- - --- ---- ------ -f------- r -" TQ - r� i ------ -------- (Draw ex--isting--=----------and--------required---------additio------------n---on-- -reverse--------- -----sid-e-)----------------------------------------------------------- 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 1-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 Workm n's Compensation laws of California." Signed .-_ 1 - - ------- --- -- --------------------------- By ---- -------- ------ ' Owner ------ ------------ BY ------ .................. Title ---------------- other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY BUILDING PERMIT ISSUED . - ----------------- DATE ------ - ". ' -?f- - ---------------ADDITIONAL COMMENTS --------------- ------------------------------ ------------------------------------------- ----------------------------- --------------------------------------------------- -- - ---------------- - --------- -- ----------------------- --------------------------------------------------- -------- Inspection by: ___-_ _ - - - --------------------------------------------------------------------------------------------- - --------------------------- --Date ------ -"'o� ��------------------- Final ----------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M