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FOR OFFICE USE. t APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ----------------------------------------------------- This Permit Expires I Year From Date Issued Date Issued Application is hereby made to he San Joaquin Local Health District for a permit to construct and install the described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations�eir. 4 work JOB ADDRESS/LOCATION .___.. �- -- -- - -------------- --------------LL -- -----CENSUS TRACT Owner's Name ------- -------------------- -------- ------- ---- - --- --- p PY Address --- -- -- -- --------- -a-- - - --------moi City Contractor's Name -- - - --- -- ---- -- - -- -��.------- - - -------- .License # _�I��l � ` Installation will serve: x Residence•�(Apartment House 0 ----- Phone _��" Commercial ❑Trailer Court i❑ IMotel ❑Other -------------------------------------------- Number of living units:------ Number of bedrooms ____.._Garbage Grinder --_-____.__ Lot Size _ Q___ �t� I - ---------- ------------ Water Supply: Public System and name { - -------------------------------- ---------------- = 4-----Private Character of soll to a depth of 3 feet: Sand ❑ Silt ElClay 0 Peat❑ Sandy Loam4[J'.s Clay Loam ❑ Hardpan ❑ Adobe 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 Itank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------ O --------- =--- ---- - ------ Liquid-Depth ------------------------ Capacity -- --------------- Type -------------------- Material---------------------- No:,_Compartments Distance to nearest: Well _--._-_--._----- -------------------_------Foundation LEACHING LINE -----------------'- prop. Line - ---------,-••----- [ ] No. of Lines ------------ ----------- Length of each line---------------------------- Total -Length -----------_- D' Box ___I____.__ Type Filter Material _________________-.Depth Filter Material------__"------------------------------------- Distance _______ _-_Distance to nearest: Wel! ____y_____ _____ Foundation ------------------ Property Line _--------------------- SEEPAGE PIT I [ l Depth --------------- "-- ..Diameter: � ,'�• Number R Filled, -- --- --------------- ----- Rock Fie Yes No .0 Water Table Depth -------------------------Rock"Size _ - ' REPAIR ADDistance to nearest. Well - -------•------------Foundation -----------------•--- Prop. Line -----------•---- REPAIR/ADDITION(Prev.(PreySanitation Permit# ----------------------- ------ - " - Date -------------------_--- Septic Tank (Specify Requirements) ---------_-------____ f '` - -- - x - - Disposal Field (Specify Requirements)..- - -- ----- lY --------------------- _ --------------------------------------------- I _____ __ _________ ____I herebycertify that 1 have prepay (Draw existing and required addition on reverse side)" Y ed 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 i sed agents signature certifies the following: E "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." Signed ------------------------ ------------ ------------------------------------ Owner BY ---- ------- ------------------ --------- Title ------- (if other t n owner) ------------ --------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __- 73 - ------- -------------------------------------------------------- BUILDING PERMIT ISSUED -----:-----_-- DATE --- --------- -Ih �-' ADDITIONAL COMMENTS __-- -- -_� - �7DATE ---------------------------- ------------------------ r - -------------------------------------------------------- ------------------- -- -- =¢.rt -------- - ------------------------------ Final inspection by: __ ----------- ----- i __-" - _ -- ----------Date - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. I �