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FOR FICE USE: APPLICATION FOR SANITATION PERMIT l (Complete in Triplicate) Permit No. ---.�/---------- ---------------------------------------------------------- r� ----------------------------_---.-.---_-------_------- This Permit Expires 1 Year From Date issued Date Issued - :�/_L./ 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 ith County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION �------- ----------- -- ----------------CENSUS TRACT -------------------------- Owner's Name --------------- - -- C. - --- - --------- ---- -------- ------------------------------------PhoneV77—!�.SX$------ Address - --------------PhoneV77-;�SX$ ----- Address1-------- ---- ------------ City --- ----------------------------- nn Contractor's Name ----- ------- -- i•® fi ------------------ -------- -- __License # ----- Phone Installation will serve: Residence %Apartment House❑ Commercial ❑Trailer Court ,❑ Motel ❑Other -------------------------------------------- i s Number of living units:--- ------- Number of bedrooms ---'3----Garbage Grinder ------------ Lot Size ------------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam 0 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 ---------------------.----- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -------------•-•---•-- Distance to nearest: Well --------------------------•---------Foundation ---------------------- Prop. Line ------•.--..---------- LEACHING LINT; [ ) No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------------------------;r .0 'D' Box ------------ Type Filter Material --------------------Depth Filter.Material -------------------------------------------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No i❑ . Water Table Depth ------------------------------------ -----------liock Size,-=--------------------------- -- 17 Distance to nearest: Well-----------------------------------------Foundation -------------------- Prop. Line -.-.---------_------ �6 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------------------_--� Septic Tank (Specify Requirements) ------- ---- --------- d- - -------------------------- Disposal Field (Specify Requirements) •------------- -------------- ----- ---------------------•--------------- ------------------------ ---- --- 'u — - S (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: s, "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 - ------------------------By ------ --- -- - ------ -------- #-- -- - ---- ---- Title ------ (If other t owner) "{ FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY -Gr/"f-Ile- ---------------------------------------------- DATE 2---/( 7- ------------ BUILDINGPERMIT ISSUED ----- ---------------------------------------------------------------------------------------------DATE ------------------------------------- ADDITIONAL COMMENTS . - :. t�,u -��--- �----' �- ------- ---------------------------------------------------------------------------------------------------- -------------------------- - ----- ------ Final Inspection by:- -- ----- ------- - - - --- - ------ -------- -- ---- - ---------------------------------------------------------- ------- ----------------- ----- -^ -- -- -------- ---------- ------------- -------Date --- y SAN JOAQUIN LO HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M