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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. -- ---------------- (Complete in Triplicate) ---------------------- Date Issued /1_._�--) 7Ti . ._. ----- --- -------------_---- This.Permit Expires 1 Year From Date Issued Application Is hereby made to the an Joaquin Local Health District for a permit to construct and install the'-work herein described. This application is made in compliance ith County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCAT --2 __ �'� —�� CENSUS TRACT __________________________ 4 fes' ' ' /S-` -= Owner's Name -- '` - � == } ----------Phone Address �ca, d`� 1 ' '"" ------._. City'_r ------rte_ 1�7Contractor's Name --------- License # ------------------------ Phone ------------------------------ Installation will serve: Residence X Apartment House,❑ Commercial ;❑Trailer Court ;❑ Motel ❑.0th r--------------------------------------- Number -------------------------------------Number of living units:--------f- Number of bedrooms ___Garbage'Grinder ------------ Lot Size ____________________________________________ Water Supply: Public System-and name ---------------- - -------------- -Private [ Character of soil to a depth of 3 feet: Sand'❑]SiIt:E] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan-t] 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.) y� NEW INSTALLATION:-"" (No septic flank or seepage pit permitted if public sewer is available within 200 feet,) t [ «Q PACKAGE:TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity - ----------------- ------------------------ Ca acit - Type -------------------- Material---------------------- No. Compartments -- V_ :.+• i Distance to nearest:. Well ---------------------------k'-------Foundation -------------+-------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines ------------- -------- length of each line--------------------- :----- Total Length ---------------------------- I_, , 'D' Box ------------ Type Filter-Material --------------------DepthsF,ilter Material ------------------------------------•--- Distance to nearest: Well --- k-3------------- Foundation ------------- i--------- Property Line ------------------ SEEPAGE SEEPAGE PIT [ ] Depth --- Diameter ---------------- Number. _- ------ Rock Filled Yes ❑ No i❑ ` r Water Table Depth ------------------------F------------------------Rock Size ` "-:---------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line_---------------------• REPAIR/ADDITION(Prev. Sanitation Permit# ----------------______ _\------------- Date ------•-------------- --1 Septic Tank (Specify Requirements) -------------------------- --------------- -------------- ----------- --- Disposal Field (specify Requirements) �--- k C t = Y --� ` - ------------------------------------------------I------------------=----- -- - --------- -------------- --------------------------------- - (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 subject to Workman's Compensation laws of California." Signed ----------------------------------------- Owner itle ----------------------------------------------- ------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ----- ------ ----------------- - DATE Via__' ` - -- BUILDING PERMIT ISSUED ---------------------------- --------------------- -- - --------------------- -------DATE ------------------------------------------- ADDITIONALCOMMENTS ------------------ - --------------------- - - --------------------------------------------------- -------------------------------------------------------------- ------------------------------------------------------------------------------------------------ ---------------------------------------------------------- ---------------------------------------- -- Final Inspection bY: --- u'L'_ ---- ------------------------------------------------- pate --- ,a.__-.- _. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM �. n.,: _