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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _7__.__� ----------------- ---------------------------------------- ---------------------- This Permit Expires,] 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 compliancewith County O4raIna No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION I3�/ / ! _____________ ____________________________CENSUS TRACT __-_______ _. _. _ -Owner's Name d-1-t --------- ----- ---- ' YXPhone- Address ------------ - -- ------ ---------- ---- ---- ---- ---- --- City p - _ , ----=C -- - ------ _.License # Phone -----------------------------ontractor's Name ------- ------- - --- _--- i - Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other ---- -----------------------------------•-•- Number of living units------ Number of bedrooms -----Garbage Grinder -------- --- Lot Size ____. ____ ------------- W ater ____________Water Supply: Public System and name ------------------------------------------------------------------------------------------------------ ----Private, Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay [] Peat❑ Sandy Loam ❑ 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.)'\ i (No septic tank or seepage pit permitted i ipublic sewer is afailable within 200 feet,) NEW INSTALLATION- � PACKAGE TREATMENT { ] SEPTN-0- ANK o Size _�1__ �__. __ _______ Liquid. Depth ______________ Capacity _ -- Typ ----------------- Material ----- No. Compartments -�----->---- Distance to ne est. Well --------- -------------Foundation ____ Prop-Eine -------7� ------ LEACHING .______ Length of each line______ ._�J_6__l_.____ Total' Length _rr��,©..__...._._. LEACHING LINE [ No. of Lines _____.__ g � g A` 'D' Box __ Type Filter Material -_ -�_c____Depth Filter Material -------_-/�,__------------J_____________ Distance t nearest: Well -------5140---- Foundation '_.__-119------_______ Property Line ________________________ SEEPAGE PIT [ Depth ____Q __ Diameter ---'72;;__---- Number ---- _ _ ____. Rock Filled ;Yes ( ] No 0 Water Table Depth ___ --_ Rock Size __-__ _ ____ ..___...___ ------------- ---•- Distance to nearest: Well -___ _____ _Q_ __ -_______________Foundation Prop. Line ....5-------------- REPAIR/ADDITION ________- _REPAIR/ADDITION(Prev. Sanitation Permit# __.____.--------------------------------- -- Date __________________________________) SepticTank (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, acid Rules and-Regulations of'the San�Joaquirr-L-ocal-�Health••District:=Home-owner-a.or4ken-z,:,,F 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 (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = ------------------------------------. DATE - _`_ "7', BUILDING PERMIT ISSUED ------ --A--- ----- -------------DATE ------------------------------------------- ADDITIONAL COMMENTS ----------- --------11j ------- ----4C------- ------------------------------------------ r ---------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------- ----------- -------------------- --------------_---------------- -------- --------------------------------------- --- ----- -- -- ------------------------------- ` Final Inspection by: f ------------------ '------------------Date ' SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M