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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- --------------------------------------------------- W � Permit No. w (Complete in Triplicate) _-. ----------------- ----- 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: e JOB ADDRESS/LOCATION .d.- _3__- _---- -- _'-- � CENSUS TRACT -------------------------- Owner's ----------------- - •- � --- Owner's Name --- ----------- --------------- ----- -- -------- Phone �7 -- /.��----•---- Address _7 . { aM+ilk------------------------------- City ----------------------------------------- Contractor's Name __C�/ ,� ,-_--- 3(----__-- ---_--_.License # Phone Installation will serve: Residence P'Apartment House❑ Commercial ❑Trailer Court 17 Motel ❑Other -------------------------------------------- Number of living units: -,-/----- Number of b dro m ._�- Garbage Grinder -------- -- Lot Size -7$_X-�_�.�__L.--__---_-__- 4!P AE Water Supply: Public System and name -- -cif/ -- - --- -------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ ' Clay ❑ Peat❑ Sandy Loom V Clay Loam ❑ 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 [ I SEPTIC TANK' rze__y x --------------- Liquid Depth - ------------ -------- 0 Capacity0 ,A4 __---__ TypeokA Material -- No. Compartments _____° '_....:..__ Ul Distance to nearest: Well _____l/__ P.�______________Foundation ---Ze--- _---_- Prop. Line ------------ %V LEACHING LINE No. of Lines ---3----------------- Length of each line--- __-- ---------- Total Length 'D' Box _- ------ Type Filter Material S"_ tl _--Depth Filter Material _._.-1.49__r--... ..................... Distance to nearest: Well - _^0--------- Foundation `-- , ----- Property Line ---�$7............... SEEPAGE PIT Depth ----fD--------- Diameter _-_ -------- Number --- --- Rock Filled Yes No C1 Water Table Depth -----7-3----------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------- REPAIR/ADDITION(Prev. Sanitation Permit# --------------- ---------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------------------------------------------------------ - Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ ---- -------------------------------- ---------------------------- - --- d (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 beco s4ject tork Compensation laws of California." n's Comp Signed ----- W ------- -- - -------- Owner BY ---------- - ------------------------ ---- ------- Title -- -------- -- --------------- (If other than owner) r FOR DEPARTMENT USE ONLY '+ APPLICATION ACCEPTED BY ----- ---- --- -------------------- ------------------------------------------------------------ DATE AW-A-1-1-------------------------- - - - BUILDING PERMIT ISSUED ------- DATE ------------------------------------------- ADDITIONAL COMMENTS .-.,2 ---------- --------------------------------------------- ------------------------------------------------------------------ ------------------------------------------ 3-r � '`�''=�' --------- ------ -------- ------------------------------------------------ ------------------------ - -- - - ----- - ------------------------------------------------------------Inspection by: ____-- e.-2 ------------------Date ----- --- z — SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M