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i r FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT a ----------------------- F' Permit No: l _ iComplete int Triplicate) ------------------------------- This Permit Expires 11 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 ywith �County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIONZ. ..'w____'_`' - -----------------------CENSUS TRACT __--_---_______._r-__- Owner's Name - ---- - --- -- ---- -- ----- - ------------- ,� �Q Phone., 15_ "3(g,5--------- Address ---------------------------- -�---------r-------- --"_--- —- - ---_CCitY ----4" ` --------------------------------------- - --•- - Contractor's Name ------------- / - _e__------_.License ------ Phone Installation will serve: sidence [XA/partment_}louse❑ Commercial []Trailer Court ;❑ Motel ❑:Other-----'--------- ---------------------- Number of living units:.___(. _____ Number of-bedrooms �.,_73_r__Garbage Grinder ------------ Lot Size ___ ----------------------- Water Supply: Public System and name -------------------- ------------------------------------------------------ ---------------------------------Private Character of soil-to a-depth of 3-feet: - Sand'❑/Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan-LI Adobe-E] 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 ---_________________.___-- �1'Ca acit _______ Type ____________ __ Material----------------------- No. Compartments `• Distance to nearest: Wel! --------------------------------------Foundation ---------------------- Prop. Line ________._.._:_.______ .LEACHING LINE [ ],','No. of Lines ------------------------ Length•of, each line---------------------------- Total Length _____--____._______-_...____ � •De Depth Filter-Materia! _____________________'D' Box ------------ Type: F.i!#er.JVlaterial--------------___-_- p. <' Distance to nearest: Well ------------------------ Foundation ---------...-----`------ Property Line 7_ ---------__._=_:--i - =: SEEPAGE-PIT [ ] �' Depth -------------------- biometer ________________ Number ---------------------------- Rock Filled Yes ❑ No Water Table Depth -1------------------------------------ •Rock Size E Distance to nearest,-Well ------------------_'__`_.z. "`_,_____Foundation __------------------ Prop. Line ----------------- REPAIR/ADDITION(Prev. Sanitation Permit"# _.------------------------------------------ Date ---------------------------------- Septic Tank;(Specify Requirements) _ ___ Disposal .Field (Sped{ Requireme ts) "`"`� '.'. /Cc -s --- - -------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby_certify that I-iave 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- ,4u sed agents signature certifies the following: ' "I certify that imthe performance of the work for which this permit is issued, I shall not employ any person in such manner as to-becorne subject to Workman's Com pen sati.on.laws,ofYCalifornia." - Signed --------------------------- -- ""-------- Owner ------ Title ------ --- (If oth an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCE TED BY _._-- ^--------------- DATE -1 -- '-7------------------ -- - BUILDING PERMIT ISSUED ------------------------------- -----------`" ' -- `------------------DATE ---------------_---- ADDITIONAL COMMENTS ----------------------------------------------- =------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - -- -- ---- -- -b - -------- -- - - - ----- - ----- ---- ---------- ---- L Final Inspection y ----------- -Date ---------- ----- - V-------- SAN JOAQUI LOCAL HEALTH DISTRICT F_ H- 9 1.'68 Rev_ SM