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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. �':- ___I (Complete in Triplicate) Perm -- ---------------------------------------------------------- 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 Cou y Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI - �r__ _ ------------------------------------------CENSUS TRACT ----- Owner's Name .___ ;X___-- -� 9 A one l ------------ - Address ��, �n+r �� iy 2' -- ----------• . CitY - ----- GG ,�,� ---------- Contractor's -- ----- - -----LL-J--- Contractor's Name _-- �� _ _ i --- _ -- - -----, ,�, ----------._.License �._6__ Phone - ---( '1'-�- � Installation will serve: Reside ce ❑Apartment House]] Commercial ❑Trailer Court Motel ❑Other ------------------------------------------- Number of living units:__ ----- Number of bedrooms _______Garbage Grinder ----/------ Lot Size I Water Supply: Public System and name -------------------------------------------------------------------------------------------•-••---------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt Clay rX Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ____________ If yes, type __________-_______--_--- v�. {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 f ] Size---------------------------------------- Liquid Depth ----------------_--------- Capacity -------------------- Type ____________________ Material---------------------- No. Compartments - Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------_--_--. LEACHING LINE [ ] No. of Lines ---- ------------------- Length of each line---------------------------- Total Length .__-________-__ ----------- '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 ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ________......._.__ REPAIR/ADDITION(Prev. Sanitation P ermit#,__ Date ________________ _________ --- Septic _Se tic Tank (Specify Requirements) -----Q- ) --- Disposal Field (Specify Requirements) - ------ ------ ------------------------ ----- ----------- ------------ ----------------------------------------------------------------------------------------------------------------------- (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 Son 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 gbie�ct to Workman's Compensation laws of California." Signed ----------` " l L/ 1-------------------- Owner By ---------- ---------------------------------------------------------------- Title ------ --------------------- -- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- -- ----- - -- --- -------- -------------------------- ----------------------------------- DATE _�-"�C__"7 BUILDING PERMIT ISSUED ------------------------------------------------------------------------ ----------------------DATE ------ ADDITIONAL COMMENTS ------------ - ------------------ -- ------------------------ - ------ --------------------------- ------------- ------------------------------ --- ---------------------- ----- _ -------- - Fina Inspection by: --- -------------------- ---------------------------------------Date ------------- - 70 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M