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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---- ------------------ -------------------------- (Complete in Triplicate) Permit No. { 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/LOCAT N -S 9-Y------------/ <Z,-r- - - ' ..CENSUS TRACT -------------- ----------- Owner's Name = x --------- -------- ------- ------------------ _ ---- -Phone ------------------------------------ Address ------ -. �...... f ------------------------- -- City ----' lf Contractor's Name +l\�— I//��l ✓ ' ` . License #��i� Y------ Phone ----------------------------- �Kb. Installation will serve. Residence [Apartment House❑ Commercial OTrailer Court ;❑ _. 1 Motel ❑Other Number of living units:------ ---- Number of bedrooms - -------Garbage Grinder 7 5... Lot Size -------------- ---_-_-----.---.-.---.-_--- Water Supply: Public System. and name --------------------------------------------------------------------------------------------------------------Private d Character of soil to a depth of 3 feet: Sand 1lt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ :. e ---- ---- - ------------- } �, 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.) p NEW INSTALLATION: (Nod septic tank or seepage pit permitted if-public sewer is available within'200 feet,) PACKAGE TREATMENT [ } ,SEPTIC TANK'[ I Size----- ------------------------------------------ Liquid Depth -------------------------- 1 Capacity -`=----------------- Type -------------------- Material---------------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------- Prop. Line ---------------- E , LEACHING LINE [ ] No.- of Lines ------------------------ Length of each line------------------------ __ Total Length _---___-_-.---.---------_-. 'D' Box __- _______ Type Filter Material --------------------Depth Filter Material --------------------.__----_------._...._-- Distonce to� nearest: Well ------------------------ Foundation --------------------- .Property Line ------------------..---- \ SEEPAGE PIT/ 1 [ ] .Depth ___________________ Diameter --------------- Number --------------------------`- Rock Filled Yes [] No 0 Water Table Depth --------- --------------------------------------Rock Size --------------------------------- D,istbnce ------------------------------ Distance to nearest: Well __,- -------------- __ -- ---------Foundation ---------------�___ Prop. Line ......... ------------ REPAIR/ADDITION(Prev. Sanitation',Permit# ------------ ------------------------#----- Date ----------------!--------'"-----I Septic Tank (Specify Requirement;s) ---------- -- `- ,,, _ I ., : Disposal Field {Specify Require. :ents) -- '"c�---�----- ----------------------------------- r �" -�- !r �' Z� H -------- t ---------- , i(Drw existi and requ9red 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 Rejulationsrof the.San Joaquin Local Health District. Home owner or licen- sed agents signature"certifies the following: e I "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." ; Signed ---------- f - ----------- ---------------------------------------------- - Owner By ------------------- -- ( '� : - --- --- -'c-L- Title --.- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------------------------------------- DATE --- -------------- BUILDING PERMIT ISSUED -------------------------------------- ------------------ -DATE ------------ ADDITIONALCOMMENTS -------------------------------------------------------------------------- ---- ----------- -------------------------------------- ------------ -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ---------------------------------------------- --- - ------------- --------- -----------'----- - --------- Final Inspection bY: :--------------------------------------------------------------------- - Date ± :. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M