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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT g (Complete in Triplicate) Permit No. - • ' ---------=----------------------------------------------- ----------------------------------------- This Permit Expires f Year From Date Issued Date Issued3__. 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 .-------- --- -- Q,_.__l✓------JYJ-)911✓_-----$-__�7--------------------------CENSUS TRACT --- -=- ------- Owner's Name -------- -------------------------------------------------------Phone Address ---- b �"�� Ze--------o,�------------------------------------------ City ------ --------------------------------------- Contractor's --------------------------------•------ Contractor's Name .1= C�J129/ ' '----------------------------------------License Phone _`�6� Installation will serve: Residence [g Apartment House-[] Commercial ❑Trailer Court Motel ❑Other ---- --------------------------------------- Number of living units:..... _--- Number of bedrooms ________Garbage Grinder ___________ Lot Size _________________________________________ Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand tg Silt❑ Clay ❑ Peat❑ Sandy Loam 0 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 [ ] SEPTIC TANK [ ] Size____________________________________ ___________ Liquid Depth .--______________________- 0 Capacity -------------------- Type _______-_-_______-__ Mater al________-__-- - No. Compartments ----------------_---- Distance ------------- - O Distance to nearest: Well ---------------------------- -•_---Found ion ---------------------- Prop. Line ----------------...... . I LEACHING LINE [ ] No. of Lines ________________________ Length of ea line.______ .____._________.__ Total Length __________,___-_______-____ 'D' Box .__-________ Type Filter Material ____ ______________De th Filter Material __________________.________-______-____._ Distance to nearest: Well __-________________ ___ Foundati _.______________________ Property Line __________________-_-___ SEEPAGE PIT [ ] Depth ____________________ Diameter _______ _______ Numb ____._______________________ Rock Filled Yes ❑ No i❑ Water Table Depth ----------------------- --------------------- --Rock Size -------------------- Distance to nearest: Well `._______._Foundation -------------------- Prop. Line ______________________ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------- ------------------------------------------------------------------------------•---------------------------- Disposal Fie (Specify Requirements) ____�� d________moo__ f- -___ ...... - _liV �=- r s wr - ------------------------------- -------------------------------------------------- ---- --------------------- (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, 1 shall not employ any person in such manner as to become subject to Work n's Compensation laws of California." Signed -a--- --- Owner BY ------ �. - -- - ------- -------------------------- Title ------------------------- - - ------------------------------------------- flf other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ------------------------------------------- -------------------------- ------- DATE ----- BUILDING PERMIT ISSUED - ----------------- --------------------- ----------------DATE ------------- ----------------------------- ADDITIONALCOMMENTS ------ -------- ------------------------- ------•-- •--•---- --------------- ----------- ----------------------------------------------------------- ----------------------------- ------ ------ ----------------------- ------------------ - ----------------------------------------------------------------- ------------------- ---------------------------------------- -------- --- ------------------- ------- -------------- Final Inspectio -gate ---- r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M co