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FOR OFFICE USE:. s _ APPLICATION' FOR SANITATION PERMIT 1! 0--- - - ------ '' Permit (Complete in Triplicate) - ------- - �--------------- w --------- I __-_ ___ _____ _____ This Permit Expires 1_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 despribed. This'application is made in compliance with County Ordinance No. 549Aand existing-Rules and Regulations: I � � I l JOB ADDRESS/LOCATION - _________CENSUS TRACT ___� ------------- --------------------------------------- ----________ _ - f Name ----- -- --:Phone ------------------------------------ Owner'sAddress $ -- �- '-------- City ------ Contractor s Name __ __-A_ r�` . __..__ __ _____ __________-License # +. ' > -_ Phone _ :_ .I 41 Z Instal lation,wilI serve: Residence ® rtment House❑ Commercial:❑Trailer Court '❑ f 'pai Motel ❑Other --------------------------------------------- _ # s Number of living units:-___---y__ Number of bedrooms - _--__G rbcige Grinder ' Lot,Size s®�__ Water Supply: Public SystemY and name ----------- _- _ 1A) _ ___ ____- __-__ -_____ _ __________________ __ ____________Private ❑ f ------- --- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam:0 Hardpan ❑ Adobe -Fill Material ________"'_ If yes,type ---.______________________ (PI'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 9y li NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK [ J Size------------------------------------------------ Liquid Depth __ Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------ ----------.- ' Distance to nearest: Well _.-_______________________________Foundation. ------------------- Prop. Line ---.-----------_...... LEACHING LINE [ ] No. of Lines __ .�______ Length of each line______________CK_O_____---Total Length ,_/_�-____________.__ E ' � 'D' Box ________ Type Filter Material --------------------Depth Filter Material -------------------- ........... Distance to nearest: Well ------------------------ Foundation ___ Property Line. - ----- . ----•--- f SEEPAGE PIT [ ] _Depth °--. .___ __- Diameter ___3J-- Number ___� `'__ _ Rock Filled Yes '�No i❑ Water Table Depth ---- ------------ ,_�_r_-- -----------------Rock Size --------------------------------- Distance ________ __ - Distance to nearest: Well ----------------------------------------- Foundation ---- ---------"Prop. Line ______________________ -� REPAIR/ADDITION(Prev.-Sanitation Permit# - =: Date _____________ _______ ______ __) t ` Septic Tank (SpecifyRequirements) _______ _ _. � __ t _=" - - ..2.. " Disposal Field (Specify Requirements) - - •---- '.a E S l _____________________________-------------------------------------------------------------------------------_______________________________________________________________________________________________ (Draw existing and required addition on reverse side) ` I hereby certify that 1 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- seal 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 bec a su *ect to Woan's ompensati.on las,of California." Signed ........ ---�. ._ _ -- ma a -- Owner - BY ---=--------------------------------- - - - ---- ------ Title------ Title - --- - - - - -------- --------- --------- ---------- -------- (If other than owner) A1tTMENT USE ONLY APPLICATION ACCEPTED BY _______ ------------------------ ---------------------------- DATE ------Z-=&!;�,d---------------- BUILDING PERMIT ISSUED ------- - - - ---- ------ -- - --------- ----------------------------------------- ------ ------DATE ------------------------------------------ ADDITIONAL COMME� ______- - - --------------- ------- 70 -------------------------------- ----- ----- --- -------- --------------------------------- -------------------- ------- --------- - --- ----------- - Final Inspection b Date __- _— - NQUIN LOCAL HEALTH, DISTRICT E. F'. 9 1-'68 Rev. 5M