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;,s .' A FOR OFFICE USE: v o APPLICATION FOR SANITATION PERMIT --------------f/------ --------- f� '` Perrriit No. (Complete in Triplicate) - ---------------------------------------------- ��•; -_-------------------------------_------_--_--_-- This Permit Expires T 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 Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI ---� ? d�'a--:---- . 1Z _4_1'1------- d------X --d-- CENSUS TRACT -------------- -------- Owner's Name ------- k�_.la----t__ -�r,J------------------- Phone Address -------------- .__ = - � _ = City ------------------------------------- ------------------------- Contractor's Name -- /z - a~ License # __a!� ___S'y Phone Installation will serve: Residence [ partment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ___________-_ Number of living units_____________ Number of bedrooms 2-------Garbage Grinder ------------ Lot Size .......A- _tea' ------------ Water Supply: N iblic System and name ----------------------------------------------------------------------------------------------------- -------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan �r Adobe ,M 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,j PACKAGE TREATMENT f ] SEPTIC TANK [ ] Size--------------------- ----------------------- Liquid Depth -------------------------- Capacity --------------------.---- Ca acit T e Material,---------------------- No. Compartments 4 Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line.'---------- ------ i LEACHING LINE [ ] No. of Lines ____ _______ Length of each line----------------------------- Total Length ---------------------------- 'D' ______:--_-_________-_._.-- 'D' Box ------------ Type Filter Material ---------------�_'Depfh Filter,Material -----------------------------..------_._... Distance to nearest: Well-----------------------' Foundation ------------------------ Property Line. -----------------,...._- 3 SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----_------------------------------------Foundation ------------"-----:_ Prop. Line __---------•--.•---•-- REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date --------------------------------- SepticTank (Specify Requirements)------------------ -- ---------------- -------------------------------------------------------------------------<----- --------------------- ��-r , � -4 . ,---- ----- -- ------- Dis al Field {Specify Requirements) ____ _ __._----.amu-- _ ___-_-- - -- --------- t sem--- ------- i r =e� .-e -------=73-------X- Vx- -�---------------------------------------------------------------- ------ U 0 [Draw isting 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 to Workman's Compensation laws of California." Signed --------- Ow ner - _l - vTitle BY - -- - ------ li (If other than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE - - BUILDING' ISSUED ------------------------------------- --------- DATE ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- ------ ----------------------------------------------------------- -------------------- ------------------------------------------------------------------------------------------------------------------------------- ------ -------------------------- ----- ------------ �X- - - - ----- - - -- Final Inspection by: ___ Date ---------- ----- -��J � SA�QUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM