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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ----- �^ Permit No. _�Q__�� -- -------------- - � ---------- [Complete in Triplicate) ---------=----------------------------------------------- __________________________________________--------.------ This Permit Expires 1 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 with County Ordinance No. 549 and existing Rules and Regulations: Mr4N _F(A? JOB ADDRESS/LOCATION _ l_ _--- =�--------1/ + !l/-/ ��- _ -- .�-- ------------_-------CENSUS TRACT Owner's Name --�--�'- 3- - -- ----�-=------ -------•- ---------- --------------------------------------------- -- - --Phone ---'-`�:��----�-----••- -• -- Address ---&- � -------- ----------- ------ ---------- City --- -- /----_--. ------ ---- - ------ -3,97 Z ----------------------------License #Contractor's Name __ _, _------� � ------------') ` will serve: Residence 7 Apartment House❑ Commercial :❑Trailer4G&uit ;F_ / Motel ❑Other _ ------------------------------ N f � Number of living units:___________ Number of bedrooms _____.Garbage Grinder _ . .p. tot Size .__ �� _ _._____._______ Water Supply: Public System and name ---------------------------- •----------------------------------------------------------------------------Private. Character of soil to a depth of 3 feet: Sand Silt E] Clay E] Peat ElSandy Loam ❑ Clay Loam E] Hardpan C] Adobe ❑ Fill Material -AIjO--- 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 ( I SEPTIC TANK'[ ] Size-----------------------------------.------------ Liquid Depth -------------------_-_-___ Capacity -------------------- Type -------------------- Material----------------- ---- No. Compartments ------•----• ......... Distance to nearest: Well ------------------------------------Foundation _.-------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ----____---------------- Length of each line---------------------.------ Total Length ---------_---------------- 'D' _______- _.___--_-.__--__-_'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- Distance to nearest: Well ---------------------__ Foundation _______________________ Property Line _______________-____.--- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------------------- Rock Filled Yes ❑ No 0 Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .----•-----.---------- REPAIR/ADDITION(Prev. Sanitation Permit# _•------ ----------------------------------- Date -------------------------_-------_) SepticTank (Specify Requirements) ---- ------------------- ---------------------------------------------------------=---------------------------_-------------------------- Disposal Field (Specify Requirements) --------ADD-----------/Q ' , A y � J1}NeTra�l--- gpu------T ------SE:P'rr-C-----TANS ------------------------------------------ - - ------------------- - - - - - - - --------------------------------- - - ---------------------------------------------------------------------------- (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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed --- -------------------- Owner - - -------------------------=----- - z _ By - --- �� C Title --------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------` - ---------------------------------------------------------------------------- DATE 21676Y--------- BUILDING 167 ------------ BUILDINGPERMIT ISSUED ----------------------------------------- -----------------------------------------------------------DATE -------------------------------- ADDITIONAL COMMENTS - -------------------------------------------------------------- = - ---------- -------------------------- ------ ----------------------------- ------ ----------------- ---- -- ----------- ----- ---------------------------------------------------------------------- ------- - --------------- Final Inspec - - - ---- ----- Date ----- -----3 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M