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rt 'FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - -- ------ ------------------------- - `-G _- -. -- (Complete in Triplicate} Permit No. ---------------------------- --------------------------- ---------------- This Permit Expires ] Year From Date Issued Date Issued -T.j___-.:7( 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"ounly0rdinance No. 549 and existing Mules and Regulations:'AlJ'JOB ADDRESS/LOCATIO � --- ----- --- ----------------CENSUS TRACT --5 Z� �O f _ �-y Owner's Name Y!/ ------ ---- `' � /,>p Phone Address '---a------,/__ --------- -- ---- -- +.. !Stf cityF------------------------------------------------- Contractor's Name --- - - ----------- -------------- -------- ' License #1� - -- Phane ----------------- Installation will serve: Reside ce [ Apartment House❑ Commercial :[:]Trailer Court ;❑ Motel ❑Other ----- -------------------------------------- Number of living units:-------/___ Number of bedrooms __-3-----Garbage Grinder ------------ Lot Size ____-________________________.__--______- WaterSupply: Public System and naime ---------------=---------------------------------------------------------------------------------------- -------Private t Character of soil to a depth of 3 feet:'. Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam Clay Loam ❑ t Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type -___________________-____ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------ ----- Liquid Depth --_--:-------------------- ------ Material---------------------- o. Compartments _.-/_------- Capacity ---�-- ------ - - Type --------- --- NCp --------- Distance_to—nearest:—Well ---_-------------------------------Foundation -------------- ______ Prop. Line ---.---------:_------- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------------------ ------ 'D' Box -_ Type Filter Material ____________________Depth Filter Material _____.__ _______--- Distance tof'�nearest: Well ----- ----------- Found'afion—-----`---------=------ Property Line, ____.'------------------ + µ'•# SEEPAGE PIT [ ] Depth ______.__._____ Diameter ------------ -- Number ------------------------- -• Rock Filled Yes E] No C3 Water Table Depth .,,-' ______.Rock Size --------------------------------- Distance _---_------------------- - � Distance to nearest: Well--------------------------------•--------Foundation -------------------- Pro�p. Line -c-----------`-------- � i REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- Date----------------------------------- ' Septic Tank (Specify Requirements) --------------------------------------------------------------------------------- ------------------------------ ---------------------------- o ------ - --------- l-------- Disposal Field (Specify Requirements) G -- - --------- -- - --------------k---------------------------------------------------------------------------------- ------- ------------------------ Y - -------- ---- -- --- - - - ---------- Draw existing and required addition on reverse side) I 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 Compensation laws of California." Signed -------------------------------------------- Owner __ Title --- -- - --------------------- (If other than owner) - FOR .DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY ___ _ s, v - - - -- ------ -------------------------------------------- -- DATE _f- =!2'- BUILDING PERMIT ISSUED ------------ - ------------------------------DATE .-------------------- -------------- ADDITIONAL COMMENTS ------------ j ---------------------------------------'--------------------------------- ---------------- ----------------- ---------------------------------------------- ------------- ------ ------------------------------------------------ 1 ------------ - Final Inspection by: ______ __ Date 7-,z- - -, - --' -- -- - ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M