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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------•<------------------ - f (Complete in Triplicate) Permit No. .--_______�_________-, - _____________ This Permit Expires 1 Year From bate Issued Date Issued i 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 complia ce with C/ojun�ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ION - - -- "�^`_- CENSUS l- TRACT $y f 1. Owner's Name - ------- ------ ------------------------------------------------------------Phone ------------------------------------ \Address ----- + e� ► - �" -- -- - ------------- City ------ I • � " Contractor's Name -- -- __-- M -- `-----( 1.y4 4 ----------- --•----- _.License # _ 1`g_ r- Phone ------------------------------ Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court '❑ Motel ❑Other ____ _--'` Number of living units:------ __-- Number of bedrooms __7 '___Garbage Grinder -----------. Lot Size ___________________________________________ Water Supply: Public System and name ---------------------- -----------------------------------------------------------------------•---------------Private (� Character of soil to a depth of 3 feet: Sand'❑ Silt Or Clay ❑ Peat❑ Sandy Loam O!( Gay Loam f❑ 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.) (t } NEW INSTALLATION: (No septic tank or see ge pit permitted if ublic sewer is available within 200 feet,) 4 PACKAGE TREATMENT { SEPTIC TANK [ Sized _� _ .Y ° ' o � ----------- Liquid Depth -- -------------------- Capacity � _. Type �___________?_ Material_ -@. _,__ No. Compartments r i Distance to nea st: Well ------------5tt_'_____________Foundation _--___�_ _________ Prop. Line _____'.�---_--------- LEACHING LINE, [or, No. of Lines ---------3�-------- Length of each line--------pk_------------- Total Length ---Z_1a_A_--___________ ` \. 'D' Box --- ----- Type Filter Material _-_--- -_a�----Depth Filter Material _____l'L_ _____________________________ 1 Distance to nearest: Well. ---10--------- Foundation ------ ------------ Property Line. ___��________________ SEEPAGE PIT [ ] Depth --------- ---------- Diameter-------------- ---- Number _____.__----\__________ Rock Filled- Yes E] = No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well _._______._ rt - -- -------------------------Foundation -------------------- Prop. Line .------------------ - -- 1 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- Septic --------------------------------_Se tic Tank (Specify 4uirements) --------------------•-------•---------)------------ , t -•-- Disposal Field (Specify Requirements) __________ _____ ------ ----------------------------------------------- ---------- -- -- ------- --------- --- - ------- --------- --------- ------------- ------------------------ ------------------------------ 4 ._. �'` (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, 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 BUILDINGPERMIT ISSUED ------------------------------------------------------------------------- ---- ---------------------------DATE -- ------ AODITIONAL COMMENTS = --------- _ ----------- ------------ Final Inspection by: ------------- ---- - ----------------- ------ ----- ---- ---- ---- E i SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M = '�