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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 'A Permit No: ---7i------------ (Complete --- ---_--(Complete in Triplicate) Date Issued --- This Permit expires 1 Year From 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: JOB ADDRESS/LOCATION ._: - is" -- ---- ACT ,__._-CENSUS TR _---_---: --------- i Owner's Name ------� �-l-Ji.------��li-/ , Phone y ------------------------ Address ----cZ2--q V 5-------�----- - �%t� --------------. city �1 Y1 _ -C'�r/---------------- -� J— •----�1�'�--( Ile-----------------------------------LiPhone # 3-��d Contractor's Name -_-.-t� •.-.- •- Installation will serve: Residence [Apartment House-F-1, :❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units:--___�__-- Number of bedrooms __5------ Grinder ------------ Lot Size Water Eg 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 ------_-------------------- N (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----------/un -------------- --•------ ---- Liquid Depth ------------------------- -- Type ------------ ------- Ma ----------- ---------- No. Compartments ------------ ----:••-- ' Capacity --- ------- - Yp Distance to nearest: Well ----------- ---------------- Foun ation ---------------------- Prop. Line ----------------•.---- LEACHING LINE [ ] No. of Lines -------------------- -- Len h of each ----- -- ------------ Total Length :----------•-----------_-- D' Box ------------ Type Filter Mat vial ------------ D pth Filter Material --------------------•-----------•-------•-• Distance to nearest: Wel! -------- --------------- Fouon-�----------------- ---=-- Property Line ---------•- SEEPAGE PIT [ ] Depth -------------------- Diamete ___----_-_----__ N _.__---------------_ _____ Rick Filled Yes ❑ No I❑Water Table Depth ------------ --------------------------- ock Size -------------------------------- Distance to nearest: Well - ---------------------- ------- Foundation -------------------- Prop. Line ----------_--------- REPAIR/ADDITION(Prev. Sanitation Permit�# ------ ------------------------------------- ate - ---------------------------------I Septic Tank (Specify Requirements) ------------------------ --------------------------------------------------- ---------------------------..--------------------------- r Disposal Field (S ecify Requirements) -_- - ---- C ---- P " 7 c__-- ---------- ------------------------------------------------------------ /off�s--------------------- ---------- z. r�. = . --- --------- - _. __. - - ------------------- - ----------------------------------------------------- f (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." c Signed --"---- - ---------------------- Owner Title ----------------------------------- ------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY 7 APPLICATION- ACCEPTED BY ---------- ---------------------- ---------------- - DATE �. BUILDING PERMIT 1i ISSUED -------- ------------------ ------------------------ ---------------------------------=--- ----------DATE ------------------------------------------------- ----------------ADDITIONAL COMMENTS : ------ ---- --- --------------------------------------------------------------- ------------- ------------- --------------------------------------- ------------ -------------------- - - ------ --- _ ---------------------- ------ r ti --------- ----- --------- ------------ - --------- ------- - -- -- ----------------------- - ------ -- - -- -- ----- - - -r--- ------- ---- Datet -Final Inspection - -- ---- SAN. f JOAQUIN- LOCAL HEALTH DISTRICT �p € 314C7 --.._. E. H:9 , 1'-'68 Rev. 5M:, ,,-