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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.7� 7� ---------------------------=------------ _--_ ___ _ -------------------------------------- ---- -------------- --------------------------- --------------------- ------- ----------______________________-___.____.__.____._-_.__.___._._ This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the Son 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: ! 1't/. JOB ADDRESS/LO-CATION --- -_---------------,- AS5_'---------------- ---..CENSUS TRACT --------_- -- Owner's Name _ 0-Lo------- O------------------------------- - ! ------ ---- ----------Phone - - - --- Address _0I_..-yG._-�---------- ' ----------------------- City I�Imv_674ZJ ---------------- fJ Contractor's Name f, ......................... _ - Phone- ------- License # F' Installation will serve: Residence ®'Apartment House❑ Commercial ❑Trailer Court ❑ i Motel ❑Other ------ - -------------------------- , i 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 Sand Loam Clay Loam ,E] y p � ❑ Y ❑ ❑ Y ❑ Y ❑ 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.) A ' NEW INSTALLATION: {No septic tank or seepage pit permitted.f public sewer is available within 200 feet,] E PACKAGE TREATMENT [ ] . SEPTIC TANK [ ] Size---- ------------------------------------------ Liqu Depth __---__.__-___.______,_____ Capacity -------------------- Type -'------------------ aterial---------------------- No. Co partments -----:-----------: Distance to nearest: Well _________________ _____________Foundation ___._-_.._______ -___ Prop. Line ------------------------ LEACHING _-__-______________ _ LEACHING LINE [ ] No. of Lines ________________________ ILength of each line----------------------.._____ To al Length ,_______._-..-.._..___...__ 'D' Box ------------ Type Filter Material -- ----------------Depth Filter Mater' I ------------------_------------------...__-- Distance to nearest: Well ____________________ Foundation ._____.______.____._. _ Property Line ______________._.:____ Number ________________________ ___ Rock filled Yes No SEEPAGE PIT [ ] ' Depth ___________________ Diameter _________ _ ❑ i❑ Water Table Depth -------- ------------------ -------------------Rock Size ---------- - ----------------- i Distance to nearest: Well __...Foundation _____ ______________ Prop. Line ------------------------ REPAIR/ADDITION _-____--____-___ :__ REPAIR/ADDITION(Prev. Sanitation Permit r# _________________________ _ _______________ Date ________.___.___ ___.___.-__.__.__1 SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- -----:----------------•---------------------------- Disposal Field (Specify Requirements) --------------------------------------------------------- -----------------------------------� v--------------------------------=-- ' 4 '` 'L ----------'��'''' � ---------------------------' ` I (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 Rulet�and Regulations of the San Joaquin Local Health District. Home owner or liven- i sed agents signature certifies the following; � j "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 -- -- --- ----- ----- - ------------------- ---- ----------------------- f BY -------- - - Title ------ --------- (If other than owner)--i FOR DIEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ------- l ----------------------- --------------------- ------------ DATE ✓�(-- -'/ I BUILDING PERMIT ISSUED - -------- ----- ---------------------------------------DATE ------------- --------- - i ADDITIONAL COMMENTS -- ------ ----- ------ ----- ---------------------------- 1 ------------------------------------------ ------ -- - -----------------------------------_------------------------------------ --------------------------------------------------------------------------------------- -- - - - - - FinalIns ection b ____�_ � __.Date __ ._.- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M