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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit Na. __..____________ ____ +. -------------------- ------------------------- This Permit Expires 1 Year From Date Issued Date Issued/G_ S=_7o 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 Countyk0rdinance N . 549 and existing Rules,and Regulations: JOB ADDRESS/LOCATIO --------- ...... CENSUS °TRACT ------------- Owner's Name ----- -- ------+ -------- ; :s.,i_?"" ----- ---- - --- Phone ----------------------------------- �` Address .r .1 -.. - ��/ - --- ------ - . , City - ---- ------ -- -- 4-------------- ------------• 3 Contractor's Name -- ---- __. _ --- - ----- -- ------p - -:_--_-.License # .of7 __ Phone Installation will serve: Residence F1 Apartment House Cornme.rcial ❑Trailer Court 'C] #° Motel)<Other ----------------------------------- `` + Number of living units:.__-t�. Number of bedrooms --Garbage Grinder -------------Lot Size, - ------------------- Water ------------------Water f Supply: Public System and name ------------------------------------------------------------------------------------------------------`----Private Character of soil to a depth of 3 feet: ,Sand'❑ Silt ❑ Clay ❑ Peat ❑ Sandy Loom ❑ Clay Loom ❑ � Hardpan ❑ Adobe>< Fill Material ------------ If yes, type -------------------_-----___ 4 (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,] i PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------ . Liquid Depth�---.------•-----•--_-•_-- W\�, Capacity --- ---------- ----- Type --------------------AMaterial------------------ -- No. Compartments Distance tol nearest: Well ------------------------------------Foundation ---------------------- Prop. Line;---------------------- ' LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ---~----------_-----_----- \( D' Box ____I__.___ Type Filter Material .__,_______._______Depth Filter Material __________________________-_____---__-_•__ �T_ �... . � a �i Distance to iinearest:.Wel_l ------------------------ Foundation __.------ ---- -- __ Property Line. ---------i-____-_______ SEEPAGE PIT [ ] Depth ------_I ------ Diameter -.--_ -----------Number ---------------------------- Rock Filled Yes ❑ I No ❑ Water Table Depth ------------+t '--------- Roek`Size ----------------------------- # Distance to nearest: Well -----------------------------------------Foundation --------_Prop. Line _-__ __ __ 17— - _ REPAIR/ADDITION(Prev. Sanitation�Permit# _______------________ __________ Date ----------------------------------- Septic _________:_ ______ ) Septic Tank (Specify Requirements) _______________________ Disposal Field (Specify Requirements) r_ Q____ ___ _ i . --- -------- - s ------------ ------------------------------- --------------- ---a-.- .- t = (Draw existing and required addition on reverseside) I hereby certify that I have prepareid this application and that the work will be done in accordance with San Joaquin q 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 ofithe work for which this permit is issued, I shall not employ any person in such manner as to bec a su jgct to W rkma Compensati.onJla of California." f ' ` i Signed _.. --------- -------- Owner A k c BY - Title :------------- --------------------- (If other than ower) I x It FOR-DEPARTMENT USE ONLY "t APPLICATION ACCEPTED BY ---- - �- DATE _.__ $UILDING PERMIT ISSUED ° ----------- = -DATE ------- j'-------------------- �B --------------------------------------------------------------------- ADDITIONAL COMMENTS ------------- - - F € ``' �. ----- ---------- --- ------- -------------- --------------------------------------------------------- ' �------------------------------------- -------------------------- - a ------------------•------- - -------------------------- ------- - ------------ v - --- ---== ----------- Final Inspection b x Date __. �— p Y --------------------------------------------------------- . ��--�------ _- SAN JOAQUIN LOCAL HEALTH DISTRICT t I E. H. 9 1-'68 Rev. 5M