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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------- --------------- -- - Permit No. (Complete in Triplicate) -------- ------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued ._5 - --->. _ _ _ _ ------ ------------------------- --- _------------- 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 o � h ty Or 'npan�g� [� 54 and existing Rules and Regulations: JOB ADDRESS LOCATION _-- _AP09W-----CENSUS TRACT -------------------------- Owner's Na/me --------rN-r._-- -----�(��-�rr� / _.. Phone Q4� Address 1 -� 4 � IJ`f -s/,�¢ City f �1#� �/ Contractor's Name ?Cl�i� ---------------------------------------------------------License #�� Phone�W-,�• 7 37— Contractor's will serve: Residence P-A`p"artment House�❑ Commercial ❑Trailer Court i❑ Motel ❑ Other ----------------------------------------•--- Number of living units:..._,----- Number of bedrooms=;Z------Garbage Grinder -- ----- Lot Lot Size _ ------------- Water Supply: Public System and name ---------------------------------------------------------------------------------------------------•---------Private Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat ❑ Sandy Loam 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 seepa a pit permitted if public sewer is ava�bje within 200 feet,) f� PACKAGE TREATMENT { ] SEPTIC TANK.1 � Size.)--�__�`_Y7 -, .�_-Z-_ ______-__ Liquid Depth 7-�-------- ------- Capacity l�fla_-_ TypeOft-APF-0 Material ly4 No. Compartments ----_-_-___-. - �t Distance to nearest: Well _________________Foundation ---140-__-------- Prop. Line ________.____________ - LEACHING LINE [ No. of Lines ___-2---------------- Length of each line---A40__ -------------- Total Length _146-a-11........... 'D' Box __ Type Filter Material W,0_6< Depth Filter Material ________ ___________ _______ Jor 5, ! Distance to nearest: Well ......07 _.--____ Foundation __LD____._________ Property Line _ _____________________ SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number __-_------ ----------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation ______ ------------ Prop. Line ----------- .......... REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------- - Date -------.--------------------------) SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------------------------------------•------- Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- ------------------------ ---------------------------------------------------------------------------------------------- --------------------------------- 7- ----- (Draw existing and required addition on reverse side) 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: "1 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." Signed __-- -__-- Owner BY I ``R Title -------------- (If of er than owner) ��JJJ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __-___ !!vv -- DATE ----- _�J__------------------- BUILDINGPERMIT ISSUED --------- ------------------------------------------------------------------------------------------------DATE -------------------------------•----------- ADDITIONALCOMMENTS -------------------------------- -------------------------------------------------------------------------------------------------=--------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ ----------------------------------- ---------------------------------------------------------- --------------------- ---------------------------------------------------- -- - ------ - -- --- -------------- ------------------- - . ------ FinalInspection by- ---------------- ------------ -------------------------------- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M