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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------------•-------- -------- - --` -- (Complete in Triplicate) Permit No. ----------I--------------------•------ ------------------ _ __--------------- This Permit Expires i Year From Date Issued Date Issued,- /_..67 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 . iW11.1t----------------------------------------- -------------CENSUS TRACT -------------- ........... Owner's Name �J'f / --�!l✓l---l�F^- -- -- - -- -------------------------------------------------� --- -------------Phone ----------- ------ ----------------- Address - ---•----------------- Address --------- -----. Cit ------- ------------------------------------------------ ----------- ----------------- Cantractor's Name -------------- t0:1W ----------------License# _f 7 - _ _ Phone ----------------------- Installation will serve: Residence [TApartment House❑ Commercial:❑Trailer Court ❑ a Motel ❑Other-------------------------------------------- Number of living units:---I_------ Number'of bedrooms ____Garbage Grinder ono______ Lot Size ---F K 14� Water Supply: Public System and name - ----------------------------- - Private ❑ Character of soil to a depth of 3.feet: _Sand'❑ Silt❑ Gay Peat❑ Sandy Loam ❑ Clay Loam 'C7 Hardpan Adobe Fill Material ------------ If yes,type (Plot plan, ft—ring 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 [ I SEPTIC TANK:[ ] Size-----------------------------------•------------ Liquid Depth -------------------------_ Capacity -------------------- Type -------------------- Material---------------------- No. Compartments Distance to nearest: Well _________________________________-.Foundation ---------------------- Prop. Line --------------- r___..- LEACHING LINE [ ] No. of Lines _______________________ Length of each line--------------------------- -- Total Length ------------___.___.,__..._. t , 'D' Box ------------ Type Filter Material --------------- ---Depth Filter Material --------------------.---------- Distance to nearest: Well ------------------------ ----- ---------------- Foundation --------------------------- Property Line ---------.--•-,......... SEEPAGE PIT [ ] Depth -------------------- Diameter- ---------------- Number T___________________________ Rock Filled Yes ❑ No ,0 ----------------------p -------- Water Table Depth .-------.Rock Size ±-------------------------- _ � I ---- - - ---- Distance to nearest: Well ----------------------------------- •..Foundation --------------_.---- Prop. Line ...................... ! t REPAIR/ADDITION(Prev. Sanitation Permit r# ------------------------------------------- Date _______-__"___-____________________1 Septic Tank (Specify Requirements) ------------------- ---------------------------a--------------------------------- --------------- --------- ------ . Disposal Field (Specify Requirements) - ------ ------------------------------------------------------------------------------------------------------- --- ------------------------------------- ------ ------------------------------------------------------------•------------------------------------- ------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that 'the Iwork 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: F y "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 sub' ct to Workman's Compensation laws of California." ... _.. .. .. �.. _,. .,ten Signed - -- --- -----------------)'--T,.S --------------- Owner---------------------- BY ------------------------------------------------------------ Title (If other tha owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYW_0,40- ---0' ---------------------------------------------------------. DATE - z� `9 ---------- BUILDING PERMIT ISSUED ---------------- -- ------DATE ---_-- ----- ADDITIONAL COMMENTS = ------------------- ------------------------------------------------------------- ----------------------------- `-------------------------------------------------------------- ------------ ---------- x - - ----- Final Inspection b _ - P Y° w Date 1 G 9 - ---- ----- --- -- - SAN JOAQUIN LOCAL HEALTH DISTRICT k i 1 s. E. H. 9 1-'68 Rev. 5M ;_ -+i `