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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT qq - - ----------- Permit No. (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Date Issued 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: s. JOB ADDRESS/LOC ION G - --- --------------CENSUS TRACT .1 Y*7--------" Owner's Name ._- --- _._. .� - -Phone ---------------------------------- Address ----- ----------- 11.3.6.E _ City .-.Qom_ - - ---------------------------------------------- jr Contractor's --- -- -•`-```'" - .._X�'= cx b y License # 1683._ Phone ------------------_--------- Name Installation will serve: Residence [A Apartment House,❑ Commercial j]Trailer Court 0 Motel ❑Other----- ----------------------- .............. Number of living units!----------- Number of bedrooms __3------- Grinder --- _----- Lot Size --------- ....... Water Supply: Public System and name -------------------- --------------------------------___------..-----------_.._...-.-- Private Character of soil to a depth of 3 feet: Sand j] Silt j] Clay ❑ Peat❑ Sandy Loam ig Clay Loam ❑ Hardpan ❑ Adobe p 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[ ] Size----------------------- ------_.... - Liquid Depth ------._------_.__,____ Capacity ---------- Type -------------------- Material------ ----- -------. No. Compartments Distance to nearest: Well .____.__._.._Foundation ----------- ---------- Prop. Line ---------------------- LEACHING .____..............LEACHING LINE [ I No. of Lines _. Length of each line_.------------------------ Total Length ......___............... 'D' Box ------------ Type Filter Material ....... ------------Depth Filter Material .._._________________-__----._..._-.__._ _ Distance to nearest: Well ........... ............ Foundation ------------------------ Property Line .__.___..__............ SEEPAGE PIT [ ] Depth ._.. Diameter ._.------------- Number -----------................ Rock Filled Yes j] No Cl Water Table Depth ---------------------------Rock Size - -.. Distance to nearest: Well _.__----_.............___.__...__.....Foundation __.----------------- Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ----------- -------------------------------- Date ........:.....__.__.___..._____) Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) _ :!t!.�---- -_ -_. _. __._.___ -___ _ ILP - - - �P a �` —Q- c'— ^ae f 3' x ----------- _1------------------------ L - ----------- -------------------------- -- --------------------------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared II 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 -------...- - ; --- ----- - --------- - --------------------- Owners —q- - -- ------ -- - ---------r------------------- Title _. `Y JI - (I other than owner) -- - - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. . --------------------------------------------------------- DATE '7Y------------------ .. BUILDING PERMIT ISSUED - ------------------ ------------ ----- - --------- - -----.DATE ------------- ---------------- ADDITIONAL COMMENTS ------------------- ------------ -------------------------------- -- --- ------- - ------------- ----- ------- - --------------------------------------------- ----------- ---------------------------------------- "- - - - -------- ---------- ------- - - - --------- - Final Inspection by: _-_.-.._. .. _... _.... . . Date . SAN JOAQUIN LOCAL HEALTH DISTRICT L. E. H. 9 1-'68 Rev. 5M