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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------ - - - ------------------- Permit No. 43_-_%,)-V (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: JOB ADDRESS/LOCATION __�_ _�a-y __ _- - -----CENSUS TRACT lJ� ----- Owner's Name - r ----------------- Contractor's Phone Address 4�} I� -- oQ - City ` =--------------------------------- -------••- r r �-p Contractor's Name ._-- -. ..--. _____ ____41�-. .License # _�� ' - Phone Installation will serve: Reside ce ❑ Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other1�.? Number of living units:_#--- Number of bedrooms ----f- _.Garbage Grinder ------------ Lot Size -------------------------------------------- Water ---------------- -------------------------Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3.feet: Sand'❑ Silt❑ Clay ❑ -Peat❑ Sandy Loam Clay Loam ❑' Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ---------------------------- (Plot __________________________(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'[ ] 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 ---------------------------- 00 'D' Box Type Filter Material --------------------Depth Filter Material -------------------------------- ........... Z Distance to nearest: Well ________________________ Foundation ------------------------ Property Line -.------------_.__-____- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ Water Table Depth ------------------------------------------------Rock Size -------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------- ---- Prop. Line .....................a,, REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _____________-____________________) Septic Tank (Specify Requirements) ---------------------------------- - _ _ --------------- p Disposal Field [Specify Requirements) -----� --- __. �'�- ___.-____-___-- " �--"'X----� �--- ' _ --------------------------- ----------------------------------------- ------------------------ o ----------------------------------- - ----------------- - (Draw existing and required addition on reverse side) 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui 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: "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner r as to become subject to Workman's Compensation laws of California." Signed --------------------------------------------- Owner D �f By --------------------------------- -------------------- .J_ -Title .. - ---_-- ----------------------------------------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. ------------------------------------------------------------ DATE _?_71. -,7_ ,_:.--------------- BUILDINGPERMIT ISSUED -------------------------------------------------------------------------------------- --------DATE ------------------------------------------ ADDITIONALCOMMENTS -- ---- ----------------------------------------------------------------------------------- --------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------•-------------------------- - ----- ---- - - ------- ---- - 3 -- - ---------------------------------------------------------------------------------- - -- ---- --------- Final Insection b Date _ --__"I y 7 ------------------ PY= --- --------------------------------- -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M