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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No.-,7 /-� Q ----- -------- ----- (Complete in Triplicate) -- -- P --------------------------------------------------------- Date Issued __4/0//_/-`7---• ------------------------------------ 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. 14/6 C�e� r c : ---CENSUS TRACT --1----------------------- JOB ADDRESS/LOCATION .--- - ------"" --- - --------- - ----- - ------ - ------ -- - Owner's Name ---- � �' Address - .�' ---- ..... a ° "`----- ------- -------------- ----------- city Contractor s Name ___-- ---.- _- _License # ------------------------ Phone ------------------------------ installation will serve: Residence [V Apartment House Commercial ❑Trailer Court Cl Motel ❑Other ------------------------------------------- Number of living units:----l------- Number of bedrooms --- 3--_-.Garbage Grinder k ----- Lot Size --_ ° ---------------------------- jWater 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,) 1�. D! Y4 p'#b? 7"" --- Liquid Depth __-------- ----- W 4 PACKAGE TREATMENT [ ] SEPTIC TANK [kj Size------------7--------- -- q p Capacity AS7 t0 Type � '" ----- Material ovw............ No, Compartments -___________________ Distance to nearest: Well Length f each line�o��a�ion __-- -_ Total Length h L.lu_Z_�-�---------- I LEACHING LINE ,�+] Na. of Lines __�------------------ 9 � T 'D' Box _ - Typee.Filter Ma.e r- - - - ---------Depth Filter Material ---------------------- Distance to nearest: Well -- V__-_-_�'____-- Foundation Y¢ Property Line ------ . I SEEPAGE PIT ] Depth Diameter __-_----__-_--- Number ---------------------------- Rock Filled Yes ❑ No I [ ---------------- I Water Table Depth ---- Rock Size Distance to nearest: Well ----------------------------- ------.Foundation ------------------- Prop. Line a REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------..-----) Septic Tank (Specify Requirements) ----------------- ---- --------------------------------------- Disposal --------------------------`- -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 ' the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom act to Workman Co enration laws of California." Signed - _ �J --- Owner -- ------------------- I BY ------------ ----- ---------------------------------------------- ------------------------ ------------ Title --------- ----------------------------- -------------------------------- (If other than owner) Of FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- --------------- -------------------------------- DATE -------- - ------------- -- ------------------------- - - PERMITISSUED -------------------- ------------ ------------ DATE -- ------------------------ BUILDING ADDITIONAL COMMENTS -------------------------- - ----------------------------------------------- - - ------------------------------------------------ ------------------------------------------------------------------- Final Inspection by: _--� -- -..ar ---------- ----------- - - --------Date/-- ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1268 Rev. 5M _-