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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------------------------------------------------- f _7-1c: (Complete in Triplicates Permit No. 4 --------------------------------------------------------- __________________________.__._________--------------- This Permit Expires i 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'inpcompliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT N - f / F ---:----CENSUS TRACT Owner's Name r --- ------------------------- -- -Phone ------------------------------------ I Address r° --- --� -------. City J --------------------------------------------------------- M og f/ Contractor's Name_. , / P .. ��-- ---- -.c•--------License #<� 3t ----- Phone ------------- Installation will serve: Residence ] Apartment House❑ Commercial:❑Trailer Court '❑ l I Motel ❑ Other -------------------------------------------- ____ Number of bedrooms ------------------_..__Garbage Grinder __ ___ Number of living units:_____ ___ Lot Size _-____`�-_____________ Water Supply: Public System and name -----------------------------------------------------------------------•---------------------------------------Private 4 Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam EV Hardpan ❑ Adobe )] Fill Material ------------ If yes, type ____________________________ I (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 tafnk or seepage pit permitted if public sewer is available within 200 feet,} i PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------------------------- ------ Liquid Depth -------------------------- � , ' Capacity ------------------- Type -------------------- Material------------------ - No. Compartments -----------•-•---.---- rDistance to; nearest: Well ____________________________________Foundation -----------------------Prop. Line ______________________ yl LEACHING LINE [ No. of Lines __.___- ---------------- Length of each line--------------------- ...... Total Length ,__________-______________ _ YP --------------------Depth Filter Material ---------------------- € 'D' Box --- ------ Type Filter Material ______________________ - y E Distance to nearest: Well _____:___________:____ Founcicition :.______.___ t ---------- Property Line ......................... �. SEEPAGE PIT Depth ---------------------- -Diameter_ ______________• Number ---------------------------- Rock Filled Yes © No 0 Water Table Depth --------------- __--_--=----- - --_--Rock Size ------- -------_-_----_.__-..--- 1 Distance to nearest: Well _..____"_._-___________________________Foundatian -------------------- Prop. Line ____....__............ r REPAIR/ADDITION(Prev. Sanitation,Permit# --------_--------------_---------_---------- Date __________________________________) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•-----------:-----------------------------=--------------- Disposal Fieldf (Specify equirements) ------------------------------------------:_2---------------------------------------------------------------------------•----------- ---------------------------- ----- `r ---------------------------=------------------------ i ------------- ----------- ---- ------------------------------------------------------------------------------I--------------------------------------------------------------------------------------------- (Draw existing and requiredaddition on reverse side) I hereby certify that 1 have preparetl 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 Workma ' mpensation laws of California." Signed --- --- ------------------------ � Ownerp, - °V� Title --f`�.1�C -C4 ¢`i+ By --------------------- --------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------- ------------------------------ ----------------- DATE ------------------- BUILDING PERMIT ISSUED ---------------i'-----------------------------------------------------------------------------------------DATE -------------------------------------------ADDITIONAL COMMENTS.______________'"I --- ------------------------------------ ---- ------- Final Inspection by: `` - - Y Date Jf --- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M