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t. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - / Permit No. lComplete in Triplicate) ------------------------------------------------ q - 7j __ 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 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION .---- --1 -- -,------ ----� '�___.-----_-- 's C----........CENSUS TRACT -------------------------- Owner's Name r� �F - / f-�----- Cf:!x — Phone = �S` ,�-� Address -- `f ----- �= ------1 - - ------- --C City Contractor's Name __.___ r License #,2C.' l-7-__ Phone __ d------- Installation Installation will serve: Residence partment House Commercial ❑Trailer Court Motel ❑Other ------------------ -------- i Number of living units:.__ Number of be ooms _- _____Garbage Grinder ------------ Lot Size _- _gx_I_tS_ ��- ci... Gc� Water Supply: Public System and name ........._ _ _ , _ � - _______________________ _____________ __________________Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ 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 tank or seepage pit permitted if public sewer is available within 200 feet,) l A PACKAGE TREATMENTSEPTIC TANK'[ ] 4eLiquid Depth Capacity -------------------- Type -------------------- Material--------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .__.___-__ ........... LEACHING LINE V No. of Lines /__________ Length of each line---------IV---- Total Length .--_ d_........-- (T1 'D' Box ------/__ Type Filter Material __ _ ___Depth Filter Material ___IR________---------_______ ______ Distance to nearest: Well Foundation ------------------- Property Line ____4? ------ �L � r� SEEPAGE PIT C Depth _ _________ Diameter _______ Number ______________ Rock Filled Yes No Water Table Depth ----------��-_--_________________________Rock Size .-t�-�-� ----------------- �� 1 Distance to nearest: Well Jul`'__________________------------Foundation ------ Prop. Line ------3 REPAIR/ADDITION(Prev. Sanitation Permit# ------- ----------------------------------- Date --..-----------------------------_) Septic Tank (Specify Requirements) ------ _____- Disposal Field (Specify Requirements) -_,.�.� -- --------------------- - ---------------- ------------------------------------------------------------------------- - - - ---------------------------------------------- (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, t 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 DEPA TMENT USE ONLY �. 0 APPLICATION ACCEPTED BY --- -- ---------------------------- DATE ----- -- ------- BUILDING PERMIT ISSUED -------------------------- ----------------------------------------------DATE ----- ------------------------------- - ADDiTIONAL COMMENTS ------------------------------- ------------ -------------------------------------- ' ___________________________________________________________ ------------ -------------- _________________________________________ __ _____ __ Final Inspection by: ----------- --- ' Date --c --,---'-- SAN JO QUIN LOCAL HEALTH D1' E. H. 9 1-'68 Rev. 5M