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FOR OFFI�;E USE: APPLICATION FOR SANITATION PERMIT _ -- ---------- -----3 (Complete in Triplicate) Permit No. _______________________ ______________ This Permit Expires 1 Year From Date Issued Date Issued _Z: ' ------ 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: f ��[ JOB ADDRESS/LOCATION .. - ----------------------CENSUS TRACT _____________ ........... Owner's Name -- Phone - 7 `'] l}4 AA� •---•---- Address -------------- 1 ------------------------------------. City - ------ --- ----------------------------------------------- Contractor's Name ------------1 _-_--- . -----------------------License # r -, 1 ------- Phone '1_---- Installation will serve: ResidenceVApartment House❑ Commercial:❑Trailer Court :❑ Motel ❑Other- ---- ------------------------------------- Number -----------------------------------Number of living units:____ _ Number of bedrooms -----3�'______Garba a 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 ❑ Adobe°d 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 [ Jze----- ---------------------- Liquid Depth ------------ Capacity I, _ Type _ _________ '----- Material-_ r____ No. Compartments. ,� r; \ x� y Distance lo/nearest: Well _________ _________ _______________Foundationiw �d___� �_________ Prop. Line...'.:......`.:,.___._____ _ Len LEACHING LINE No. of Lines -------------- Total Length .�7 __ _______:_---- ___, gth of each line______ _ , _ it yp ______Depthj Filter;'Material -_-----�____ __ 'D' Box -__ .__ T e Filter Material ""' "_"_"_"_"-__.__-_ 'Distance to nearest: W,01 -___ Foundation ----14-------------- Property-Lifie'___________.___.___._.__ SEEPAGE PIT [ Depth --- ----------- DiameteE,�53-________ Number _.____�_--_--------- Rock Filled Yes f No .� Water Table Depth __ -------`----------------------Rock Size- -`--Z----- ---------------- Distance to nearest; Well % _ ______________ _____F,oun`�dat n __-- _, _-___ Prop. Line __.________.___.___._ REPAIR/ADDITION(Prev. Sanitation Permit�#'' --.---"�1_`__-____�___________r�' ate ------_.__.___--------- ----------- ) Septic Tank (Specify Requirements) - -_---•----------------- _"=- -- - Disposal Field (Specify 'Requirements) ----------------------------------------------------------'---------------------------------------------------------- F � (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work-Twill be done in accordance with San Joaquin County Ordinances, State Caws,arid"Rules`an-d.Reg ulations—W the San Joaquin,WcallHealth District. Home owner or licen- 4sed 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." i Signed -------------- --- ------ ------------------------------------------------ Owner �- BY ------ TitleA_ :_ --- - - - - ------------------- - ------------------- - ---- - ------------------------- -------------------------- (I er than owner) 3 h; F,,�N FOR„DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY ---------- l -------------------- ------------------------------------------------ DATE ----q4- �77.7----- -- J BUILDING PERMIT ISSUED D T 1 ADDITIONAL COMM J�S��7 -- -- '� :�'' �-rZo C = - -------------- --------------•---------------------------- `� f ------------------------------------------------- -------------------- ------------------- ---------------------------- ---------------------------------------------------------------_-- -------------------------- ------- ---- - - ------ D _____-Final Inspect SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M - -