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FOR OFFICE USE: APPLICATION FOR SANITATION PERAW p -------------• ------•--•---------------------- i ( 1 Permit No: - (Complete in Triplicate) - I � Date Issued _ This Permit Expires 1 Year From bale 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. JOB ADDRESS/LOCATIONJ--- J___ LIJ- s----� �/. --- !Ytf__ _y�- ----CENSUS TRACT --- .---------- / � t Owner's Name ---- ---------------------------------- •--------------- ---Phone---------------------..-----•-------- Address ------------ Cit /� '' ------------------------------------------•--•------ ----------------------- ----- �� Phone e=-� -r,J "` �� -- L `^ 11 Contractor's Name _""____-_��--��____�-_�'��t--=--- license #�/� �- � � �� Installation will serve: Residence [6 Apartment House,❑ Commercial []Trailer Court Motel ❑ Other -------------------------------------------- _ Number of living units:--Z----- Number of bedrooms __Z-----Garbage Grinder ly Lot Size - Water Supply: Public System and name ------------ -------------------------------------------------------------- -------------------------•--•--Private;] Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam .k Clay Loam,0 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.) f. NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) r "I PACKAGE TREATMENT [ SEPTIC TANK'[} Size_/X-V X-,1^----------------------- Liquid Depth ,? --=.� ------- Capacity 1/- =[=------- TYpe/,--/4/,� -- MaterialNo. Compartments -1-=-------- -------• Distance to nearest: Well __ __�' �- ------------Foundation ZP ---______ Prop. Line .- e!2........ � y O LEACHING LINE No. of Lines ----/---------------- Length of each linn`e_._S� :_----_____"_____ Total Length 1 - .__._____ 'D' Box % J Type Filter Material / Depth 'Filter Material -_..`.�-------------- • ---•------ Distance #o nearest: Wel! "f/--�~ Foundation _ _w_ --____ Property Line .__ ................ SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------------------------- -------Rock Size ----------••-------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Littre ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ----..------------------------- -----• Date ----.-.-------------.--.-------.--) Septic Tank (Specify Requirements) ----------------- •---------------•-------------•---•--- DisposalField (Specify Requirements) ----------------------------------------••----------------------------------••------------------------- ----------------------------- -------------------1----------- ------------•----------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------ --- -----•------------------• ------ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work wills done in accordance with San Joaquin County Ordinances, State Laws, and Rules and I Mgulotions 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 ��r�� i ( her than owns FOR DEPARTMEN U ONL APPLICATION ACCEPTED BY ------------------------------ DATE --- ------ a-qW----•- BUILDING PERMIT ISSUED --------------------- DATE ADDITIONALCOMMENTS ------------ ------------------------------ -------------"------------------------------------------------------ --------------- ••-------..---------- ------------------------------------------------------------------------------------------------------- -------------------------------------------------•--------------•- ------ ---- -------------------- --------------- --------------------------------------------------------------------- -------------------- ---------- -- -----------------------------•- ----- = :.: - ----- r - Final Inspection by- -------------------------------------------------------------- --- use.. Date N SAN JOAQUIN LOCAL EALTH D1 RI E. H. 9 1-'68 Rev. 5M