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FOR OFFICE USE: j APPLICATION FOR SANITATION PERMIT ---------- ---- ----------------------- '� (Completein Triplicate) Permit No: ��----�J(------ '.4 . Date Issued _ 5=__/,,��7 ------------------L_:_ This Permit Expires 1 Year From 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/LOCATION ----- _-±3S__ __ ----- / CENSUS TRACT ------------- ------------------------------------------------- c w ------ Phone Owner's `� ,_----------------------------- i Address __ ---' - F, ------------------------------ ' - ---------. ' ------ - �`4's � City ------ {- -- Contractor's Name - ----- y ` �~---- -------------------------------=--------License # ------------------------ Phone ------------------•-.--------- Installation will serve:` Residence .Apartment House^❑ Commercial : Trailer Court i❑ Number of living uniFts:_._i � Motel ❑.Other._'�_______________________________________ g ____._ Number of bedrooms c _______Garbage Grinder �C).... Lot Size _.� YY�_ C�___________ ...... Water Supply: Public System ar cl-name _` 3__ _ `,_ `}'C------------ - _----private ❑ ------------------------------------- Character of soil to a depth)of 3 feet: Sand'❑ Silt❑.., Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam.E] Hardpan ❑ AdoberO< Fill Material ------------ If yes,type ___________________________ {Plot plan, showing size of lot, location of system lin-ation 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 _------------------------- SCkN<n Capacity -------------------- Type ------------------ Material---------------------- No. Compartments --------------------- Distance to nearest: Well ------------------{---_------------Foundation .--------------------- Prop. Line ---_-----------.-__.-- a 4� I. of Lines y------------------------ Length of each line---------------------------- Total Length ---_---------------.------- E H1NG LINE Do Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- ! Distance to nearest: Well ________________________ Foundation Property Line----------._____-_-_____ SEEPAGE PIT [ ] Depth ___________________ Diameter --___-______---- Number ---------------------------- Rock Filled Yes ❑ No a Water Table Depth ------------------------------------------------Rock Size --- --------------------------`- Distance to nearest: Well ----------------------'-----------,----Foundation --------------- ---- Prop. Line ------------------_-- REPAf ADDITIO (Prev. Sanitation Permit#................................_------------- Date ----------------------------------) Septic (Specify Requirements) ____-___--___________________________ _- Disposal Field (SpecifyRequirements) -]--r-----�X------,------�---f�---- -2`-;-.-,-- ------- ----------------- ---- ------ (" - ----•--------------------------------------------------------------------------------------------- (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, I shall not employ any person in such manner as to become s ct to Woran's Comp nsation laws of California." Signed __-_--Owner ... By ------------------------------------------------- ------------------ Tit.Ie __.-------------------- By other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- --- = } DATE - ------------------------------- - -- -------- BUILDING PERMIT ISSUED - ------ -------------t`----------------------- I-'-------- --------------DATE ------- ----------------------------------- --------------------------= ADDITIONAL COMMENTS - - Final Inspection b- � �t-.--t'}' - ------ ---- - - ---- ---- ---------------------------------- ----------------------- Date _..---------------------- - - ---•------- SAN JOAQUIN LOCAL HEALTH DISTRICT ;F Cre- E. H. 9 1-'68 Rev. 5M "