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FOR-OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Triplicate) ---------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -Z.-_L_ 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 .____ __��t ---- -:____ - _CENSUS TRACT _ -` -/-..__ ------------ -------- ---------- - ---- -- ---------- Owner's Name __._57g�API:-----0a--,Z-e/ -----------------'----------------------- Phone 44 Address -- -------------+� f ---------- -- - ---- Contractor's Name � ...=---- --"...i License # Phone Installation will serve: Residence PKPIIartment House❑ Commercial.-❑Trailer Court Motel ❑ Other -------------------------------------------- . Number of living units:----- Number of bedrooms ----------..Garbage Grinder ------------ Lot Size _Z_jXJ� ___________________ Water Supply: Public System and name ------------- -------------------------------------------------•--------------------- -----------------Private ❑ Character of soil to a depth of 3 feet: Sand' Silto Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------_______ F (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) , 1 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) \ PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth _______________.__,..--. O Capacity ------ ------ TYPe -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: We'It "-"----------------------------Foundation ---------------------- Prop. Line --------..-.-.-.------ LEACHING LINE [ ] No. of Lines _-__.--__--_____ _Aength of each line---------------------------- Total Length _._______--------_-____-____ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------------•--- Distance to nearest: Well -------- i __________ Foundation ------------------------ Property Line ------------------------ :4. SEEPAGE PIT [ ] Depth -------------------- Diameter-;.J-11------------- Number ____________________________ Rock Filled Yes ❑ No 0 Water Table Depth --------------- = r - _Rock Size ________,__________ Distance to nearest: Well ____-----1- -_______________:__________Foundation -------------- ----- ___- Prop. Line __---__-..____-_.___.. REPAIR/ADDITION(Prev. Sanitation Permit# _______________'__-,�___._______-______.___ Date ____________________...._.._______} Septic Tank {Specify Requirements) ------------------------------------------ -------------- ---------- •----------------------------- Disposal Field. (Specify Requirements) ___ _ ___-' .�___ ---------- j- / = ----- �-- a ^ -- ---—--------------- - ----------------- - ----------------------------------------- ------ 1---- ------------- ------------------------------------------------------- (Draw existingand required addition on reverse side) I hereby certify tat 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: 1 "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 than owner) /FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------------- DATE ------ BUILDING PERMIT ISSUED --------------------------- ------------------------------------------- ADDITIONAL ----------------------------------Z-- -----s- - ADDITIONALCOMMENTS ----------------------------------------------------•------------------- ------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- Final Inspection by: ----------------- -a - -----------------------•---------------------------------------Date ....... --- -------- --- - --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M