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�7 FORJFfiCE USE:�-- a APPLICATION FOR SANITATION PERMIT ---�--------- --------------- A (Complete in Triplicate) Permit No- __fir__~_---l-- ------------- This Permit Expires 1 Year From Date Issued Date 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 . oS a/------ - -- ------- v--- ----------------CENSUS TRACT ----------------- -------- Owner's Name - ----- ---- --------- ---- ---------------_---� •--------------- Phone Address Qf--- ��------�--�¢-- --- City -- - ----------- -- Contractor's Name _. _ _ --------License # yQ�, Phone Installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other ---------------------------- Number of living units:____f--___ Number of edrooms _- ____Garbo e Grinder __________._ Lot Size -------------------------------------------- - ___ a _____._ 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 ❑ AdobeX 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,) d PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------- Liquid Depth .------------------------- Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance ----------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 nearest: Well ___________________ ___ Foundation ._________--_ ---------- Property Line ____-__ ---------------- _. - SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size --------•----------------------- Distance to nearest: Well ----------------------------------------Foundation ------ --------- Prop. Line -------- ............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------•-----------------------) Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ----------- ----------- Disposal Field (Specify Requirements} ----------- ------------- Fr ---- --------------------------------�onrev -------- --------------------- ----'---V fi.c�--- ✓--J--- --------------- -- --- ----- ------ -• -- �•+---R --- --Y'------------------------ [Draw existing an req ed ad ion erse side} I hereby certify that 1 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." Sig d ---------- caner - --- - ---. B � ,— -- -- . itle -- --------- - - (If other than awned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- ' -- ------ �------------------------------------------------------- DATE ----- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------- ---- ---------------------------DATE --------------------- --------------------- ADDITIONAL COMMENTS --------------------------- ------------------------- - -----------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------- ---- -- ---- ------- ----- ------------------ --- ----------- ----------------------------- ------ - ---- ----------------------------------------- - ---- Final Inspection by: '---- ��`------------------------------------------------------------------------- ti Date �' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M