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FOR OFFICE USE: F ;� - APPLICATION FOR SANITATION PERMIT -- _=i3X Permit No. -_ = r (Complete in Triplicate) ------------------ ----_--------___-__---.- 3 This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made'in compliance with County.Ordinonce No. 549 and existing Rules and Regulations: p r JOB ADDRESS/LOCATION .--------!_ -------------------- ------.CENSUS TRACT -------------- ----------- l- -- ------: �-- Owner's Name ./-- 1 `� - -----------------------------------------------------Phone -----"-------------------------•---- r Address ------------- / t . City -- -------------- ---------------------------------------------------------- Contractor's Name -- --------- ------ - _--- - -------- L7-- .-. --------License # ------.--------------- Phone -------- --------------------- ---- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ;❑ ' Motel ❑ Other ------------------------------------------- Number ------------------------- �/ Number of living units:... ------- Number of bedro1om ------:Garrba_ge Grinder 0-------- Lot Size ---�-�_---.1►"._-_-,---------------- Water Supply: Public System and name ----- l �- �� - pP Y� Y t_- -�- -----.-----�L L-.�C.�L�---------4�------------------------------------Private ❑ , Character of soil to a depth of 3 feet Sand'❑ Siltfl Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe Fill Materials- If yes, type -------:'------------------- (Plot plan, showing size of lot, location of system in relation to wells,'buildings,; etc. must be placed on reverse side.) 4 .: a NEW INSTALLATION: (No septic tank or seepage pitpermitted if 00blic sewer is available within 204 feet,) �, t y { PACKAGE TREATMENT [ ] SEPTIC TANK'[ I Size-----------------------------------------------..- Liquid Depth ----------------_-------- Capacity'_[---------------- ---------------_-,-----Capacity ---[---------------- Type ---------—---- --- Material------- No. Compartments ---------------•-=-=-- : Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line ---------------------- LEACHING LINE ] No. of Lines ------------------------ Length of each line------------------- _-,'Total Length :--------------------------- } 'D' Box ----- Type Filter Material --_---------_-----Depth Filter 'Material -------------------------------------------- Distance to,riearest: Well`----"---`---------- Foundation . Property Line. ----------.------------- i Rock Filled Yes SEEPAGE PIT- [ ] bepth _-_-''---------_--- Diamefier _-------------- Number -------------------_----- -. El No 13 Water Table +Depth ------------- ------------------F ^` ------Rock Site -.------------= Distance to nearest: Well -----------------------------------------Founclation='--------------- Prop. Line ---------------------- I F ---------.---.-------Ir REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------- ------ _-----._---------) Septic Tank (Specify Requirements) ---------------------------�-----------------------------;------------ ----- ------------------------- t 1 , Disposal Field (Specify Requirements). -------- ------�'�e- ` _=----`-`� ------------------------ ` 1 - x --- --------------- ' i1 4 ----------------------------------------------------- -----• - -- - (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 G County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Mealth 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 iri such manner as to becomes to orkman' ompe sation laws of California." i g Ll Owner Signed BY - F t �N � Title _�.�`'`�� ---------------------------------- --------------- - (If other h'a owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- _-rf, -..---- - - .1 - ,_4 { DATE ------Vin.--� =.h-- -------:- BUILDING PERMIT ISSUED -.--.-- ------- 1 ------------------------ ----- --- ------------------------------------------------- -------------------�-----=-i------- DATE - -- �----------- ---------------- ADDITIONAL COMMENTS-------------------------------------•---------------------- ---- - ------- -----_------ ------------------------------------------------------------------------- -- ----- - -- - _" z -- - - ----------------- ----------------- -- ----- ----------- ------------------------------------------------------------------- ------------------ t ------------------------------ ------------------------------Y --- �� ---- (--------------------- ----- Final Inspection b -�- -- q ✓ Date ... r SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M