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FOR OFFICE USE: n APPLICATION FOR SANITATION PERMIT ----------------------------- {Complete in Triplicate] Permit No: --------------------------------------------------------- This Permit Expires ] 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 ADDRESSAC)CATION -- - ---- --- - --CENSUS TRACT -----------------•-------- Owner's NamePhone Address ----------- City ----- ------- ------ Contractor's Name ------ --- _- __.License # - y..f_73__ Phone '3�`r� -- - ---------------- Installation will serve: Residence R_)(partme VHouse❑ Commercial ❑Trailer Court ❑ , Motel ❑Other -------- ------------------------------ Number of living units:___ _____- Number of bedrooms ______Garbage Grinder ------------ Lot Size ._ �S__,�� 4 ------- ---------------------------- Water Supply: Public System and name ----------------------- _ / C--------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand[] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ i Hardpan Adobe,,, FFill Material ------------ If Yes, type (Plot plan, showing size of lot, location of, system Rin' 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,) V ;;.., PACKAGE TREATMENT [ ] SEPTIC TANK'[ �+ Size-----------------------•------------------------ Liquid Depth ---------------------.----- Capacity -------------------- Type ----------------- -- Material-------- - ----------- No. Compartments ------- .............. Distance to nearest: Wel! ----------`-------------------------Foundation ---------------------- Prop. Line ---------------•__-.-- LEACHING LINE [ ] No. of Lines ----------- ------------ Length of each line--------------------- ------ Total Length __________ a ------------------ 'D' Box ----- Type Filter Material --------------------Depth'Filter'Mateeidl -____-__-________________________.._._______ Distance to nearest: Well -------------I_-________ Foundation s______________________ Property Line ___________________.___ 1 SEEPAGE PIT [ ] Depth --------- ---------yt,Diameter ___ ___________ Number .__f_________-____________ Rock Filled Yes ❑ No i❑,: Water Table Depth -------------------------- _ ---'----- ----------------------- sRock_Size Distance to nearest: Well --------------------------- ''`'-,Foundation?'--__---_--_--_,___ Prop. Line ____________________ i R* i REPAIR/ADDITION(Prev. Sanitation Permit# __________________________________ _________ Date ____:_________'_______.__ -__--} Septic Tank (Specify Requirements) -------------- - - j t _ 4 - ---- /1 Disposal Field (Specify Requirements) _-- -- -_-- -- - + } ---- ---- ----- ' s --- - ---- - 71 ---- -------- ------------------------------------------ /~ - -----ex sting 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 ocal 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, I shall not employ any person in such manner as to bec su ject to'W ma s '.Compensa n aws of California." --- Signed � t Owner ----------------------- -- BY ---------- -------------------- ----. — --- - ------------------------------ Title -- -------------- --------------------- (If othe tan owner[ ; r FOR DEPARTMENT'USE ONLY I APPLICATION ACCEPTED. BY ------------ ' - -----------. DATE .GI-z-� - -------------------------- BUILDING _ } _ � PERMIT ISSUED ----7---------'------- ----- ------ "-r.,".'---- ------------------=-----------------------DATE --- ------------------------ --------- ADDITIONAL COMMENTS -------------------------- ---- ---- �r ------------------- ------------------------------------ -------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ---------------------------------- Date ---------------- -------- --- Final Inspection by.. _ SAN .JOAQUIN LOCAL HEALTH DISTRICT L/ E. H. 9 1-'68 Rev. 5M v`.��"�..• ,-.j,� � `#�� *�. ��,� �*�.