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` FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT ------------------- ----- ---------------------------- Permit No. --- (Complete in Triplicate) � -------------.. -� ---------------------------------------------- ----------- _ 7 ------------------------------------ --------------------- This Permit Expires 1 Year From Date Issued Date issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein de$cribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION , - --Dxt--��17� CENSUS TRACT - f ' Owner's Name -- --- ----------- ------------------- VY" Phone I Address 1 7 ---------- --- City /p --------------------------------------- Contractor's Name .------ ' ---- �M .__.License #!�_� Phone Installation will serve: Residence [Apartment House❑ Commercial :[]Trailer Court i❑ Motel ❑ Other --------------------------- ---------------- Number of living units:-------/--- Number of bedrooms ----/-----Garbage Grinder ------------ Lot Size __-_._- Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private ' Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay .❑ Peat❑ Sandy Loam F' Clay Loom.E] 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,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth --.-----------------------! Capacity ---------------- Type -------------------- Material------- No. Compartments -------- ............. Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line -----.._--,..:..._.._- � LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ___________-_______ ........0 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -_______-_-__-____________._________------� Distance to nearest: Well ________________________ Foundation ------------------------ Property Line --------.._______---- . SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------. Number --------- ------------------ Rock Filled Yes '❑ No [] 3 Water Table Depth ---- ----------------------------------=- .---,Rock Size -------------------------------- Distance to nearest. Well ________________________________________Foundation -------------------- Prop. Line -----------._......... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------.--------------------------) Septic Tank (Specify Requirements) -------- ----------------:---------------------------------------------- ispos I Fi d (Specify Requireme ts) ___ _ �.�____ -- r_____________ ------ ---- --' eta---- .�. ,----�------ W --- - -- --------------------- . 3 - S ----- (D� i existing and required ad tion 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------------- /� Owner By ---------- U�lL-iJ�s --- Title -- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED, BY_____ ___________________ _ ___ ` ------------- DATE __ � .�73--------------- ------------------------------------------------------ BUILDINGPERMIT ISSUED .-•--------------------------------------------------------------------------- -----------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------- ----- ------------------------------------------------------------------------------------------------ ------------------- --------------------------- ----------------------------------- --------------------- ------ ------ --------------------------------------------------------------------------------------------------------------._..-.._ ----- - Final Inspection by: ------ ------Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M