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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT } Permit No. -Tq-"0 "" (Complete in Triplicate) ---------- ---------------------------------------------- 3��s- --------------- 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 described. This application is made_ in compliance with County Ordinance No 549 and existing Rules and Regulations: - i JOB ADDRESS/LOCATION I+ `� --------------------------------------- -.-.--CENSUS TRACT ---- --------------------- Owner's Name j/�- • _ -- �� -----Phone_ --- --- -- ___-- �t ---------------------------------- �5 ! = _ -- ��,C'- ----- City /a- �- f�--------<----------------------------------------- Address I Contractor's Name ----------------------------License # -CC .�Phone Installation will serve: Residence ❑ Apartment House Commercial :[]Trailer Court ;❑ E' f Motel ❑Other _._ _ ?972 Number of living units:----- Nim ber of bedrooms _:— Garbage Grinder ------------ _ _ _ ""._ Lot Size ________ _-___. _"-"-__ _""-_"""_"_""_"_" Water Supply: Public System and name ---------------------------- ----------------------------------------------------- -------Private Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 'Clay Loam .E] Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ----------------------------, i (Phot 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/Material `� [ ] C � ��--�1-� -- - Liquid Depth -��------------ij - Capacity _ �_ _____ Type ___. Compartments (� Distance to nearest: Well ------A-----------------------Foundation - - --------- Prop. Line - --/--_-..----_ Total Length /�-O LEACHING LINK {"] No. of Lines ____�______________ Length of each line___��_. ------------ ______________ -__De Depth Filter Material � _____.----------------------------- ---------- __--- 'D' Box�_._____ Type Filter Material ___._____-_�- _ p o nearest: Well ____ �___�____ Foundation,/ -----. -.. Property Llne�f______"-_____-__ Distance t , SEEPAGE PIT [ ] Depth ------------- Diameter ---------------- Number ___________"______________ Rock Filled Yes ❑ No .0 Water Tall{e Depth ------------------------------------------------Rock Size -------------------------------- Distance tl+nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________} Septic Tank (Specify Requirements) ------------------- --------------------------------------------------------------------------------------- ----- m - Disposal Field (Specify Requirements) ---------- --•------- --------------------------------- ----------------------------------------------------------- --------------------------------•--------- I I(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: "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." I Signed Owner BY - - ---------------- Title ---------------- (if other than owner) .j ---------- ------- -1 OR D ARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- ------------ --------------------------------------------------- DATE ---------- BUILDING PERMIT ISSUED -------------1________---- DATE --------- 1 ADDITIONAL COMMENTS - -------- ------ -------------=------------- ---------------- ---------------- ------------------------------------------------------- =-------- -------------------------------------------------------------------------------------------------- --------- ------ ----------------- ------------------------------------------- ----------- ----- ----- -------------------------------------- ----- ---------------------------------- ------------------------------- Final Inspection by: ----------------- L :- __- ------------,Date --sem- C -'--%- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M