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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,1 (Complete in Triplicate) Permit No. _.7Z- S d --------------------- ----------------------------------- This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._ �?2� r' --W----��o---V- _________________CENSUS TRACT -------------------------- Owner's Name _____._____ -------------------- �� r! O ------ - G--------------------------- -� ------------------------ - ._Phone --------------- ------------------- Address - ----------------- - ---' - -------- -----a-�-------------- --------. City --------- ---------------- - ------------------------ --------------•--- Contractor's Name --------- ,__ _._____ ---------------License # �_ ��. _/__ Phone :`. Installation will serve: Residence ❑ Apartment House❑ Commercial ®Trailer Court ❑ Motel ❑Other ---------------------------------------- Number of living units------------- Number of bedrooms ____________Garbage Grinder __________ Lot Size ---- ------------------------------ Water --- d_ __Water Supply: Public System and name --------------------------- ------ ---- ----- ----------------------------1�=---------------------------------Private Character of soil to a depth of 3 feet: Sand'o Silt 0 Clay ❑ Peat ..Sa^ndy Loam •❑ Clay Loam ❑ Hardpan ❑ Adobe ❑ Fill Material ----------- If yes, type _________-________________ (Piot 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 ---613_________---_-r Capacity lr��_____ Type)Oi.4Tf _V MaterialJC4M3eri/7____ No. Compartments __�--r__...__...� Distance to nearest: Wello [ ] --------��--------------------Foundation .-/ --------------- Prop. Line ----r�........._ LEACHING LINE No. of Lines --------! ------------ Length of each line____ _/ --E-_----__ Total Length ---------------- 'D' Box ------------ Type Filter Materia _________________-.Depth Filter Material _________________________________-_._•---- Distance to nearest: Well ----- ------- Foundation ------- Property Line .1 SEEPAGE PIT [ ] Depth .__________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No [] Water Table Depth --------------------------------------- --------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------.----------_-_.3 REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------.-----------------) Septic Tank (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, 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." Signed ------ -- ---- ---------- - ------------------------------------ Owner BY �th -------------- ------------------- Title .� .------------than ner) F R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ____'___ _____ _ _- 5 7 ------------------ --------------- DATE BUILDING PERMIT ISSUED --------- ------------ --------------- --------------- DATE ADDITIONAL COMMENTS //> --------------------------------------------------------------------------------------------------------------------------------- ------------------ -------------------------------------------------- --------------------------------------- - - -------- ---- ------- - - - - - - - - ----------------- ------------------ -------------- - ---- ---- - ----- ----------- Final Inspection by: . ---------------Date --i ----Z ----------- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M