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w F• ICE USE: + ' . ",� APPLICATION FOR SANITATION PERMIT -------- -------- ----------------------------------------- Permit No. 7�' ------------------ (Complete in Triplicate) ? '----------------------------------- l _____________________ This Permit Expires 1 Year From Date Issued Date Issued -----:_LT_ 7 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/L CATION . -- -' -- _-- a_-- --- - ...... -- Yy�. ---------------CENSUS TRACT -------------- ----------- Owner's Name {-"Vr-- =L ----------------------------- -------------------------------------Phone ------------------------------- --- Address --------------------=- a •---- t-A -------- . City ----------------------------------------------------------•--•-- ----------- Contractor's Name -------------- ----- License #� �� 'Z- Phone'f� E Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;0 ' Motel ❑Other -------------------------------------------- Number of living units:-------- --- Number of tiedroom& __Garbage Grindi!% ____ Lot Size - : E Water Supply: Public System and name ---- ----- - -- . - -----------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt(] Clay ❑ Peat❑ Sandy Loam.❑ Clay Loam ❑ I a Hardpan Adobe. Fill Material _ p ❑ /t�,/�--- If yes,type ---------------------------- LX (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,) -41 PACKAGE TREATMENT f ] SEPTIC TANK ze___j`�Ce _ __________________ Liquid Depth -'T _-----....-. z-6i - Capacity __�_ __.____.__-__ Type �1CAater�a l'1 No, Compartments __ __.. , Distance to nearest: Well ------------------------------------Foundation __ --------- Prop. Line ........... LEACHING LINE No. of Lines ---IDM-ength ;Ipeach line--e37t _hs-_____ Total Length - �__.----___--._- D' Box _70-n-ea-rest:-Well Type Filter ateria! _ _ =----Depth Filter Material -__ { f --------------------------- -Distance -__"__^----.____ Foundation -_/0-- --------- Property Line - -------------- SEEPAGE PIT Depth c - / -_ DiameterNumber - -------------------------- Rock Filled Yes No i❑ Water Table Depth ------/�j-5--�-------------------- ---------Rock Size -------- Distance to nearest: Well ------------- `_________________Foundation _ 4____f____ Prop. Line .. REPAIR/ADDITION(Prev. Sanitation Permit# __________________ __ --------------------- Date ____________-__________________---) Septic_Tank (Specify Requirements) ------------------------------------------------�r` ----------------------------------------------------------------------------------- a Disposal Field (Specify Requirements) --------------------- ------------------------------------------------- -------------------------------------------------------------------------------------- ------------- i ----------------------------- --- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) I hereby certify that I havepreparedthis application and that the work will be done in Vaccordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Hcen- J sed agents sibnature 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 ----------------------- -r = _= "-------------------------- Owner i f a By ------------------------------ il�---`�`---A--)----------- ;-------------- . e -- (if other an er) FO DEPARTMENT U E ONLY APPLICATION ACCEPTED BY _.. -- -- ------------------------------------------------ DATE --� _z? - ---1------------------- BUILDING PERMIT ISSUED --------- -------- ------------------11f--------------- ------- '--------DATE ---------------- ADDITIONALCOMMENTS ----------------------------------------------------- ------------------------------------------------- --------------- --------------------------- --------------------------------- ---------------- --- ------------ ------- -----------------------------------------'---- -------------------- ------------------- --------------------------------- -- - - --- - -------------------- ----- ----------------------------------- ----- ---_------ Final Inspection by: --- ------- -- --- ---- �1 -- ---- -- - ----------------------------=--------Date ------------ SAN JOA UIN LOCAL HEALTH DISTRICT �� E. H. 9 1-'68 Rev. 5M '