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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. , ...---•--. 7C - �7 , ICQmpleteInTriplicate) w. i • This Permit Expires I Year from Date Issued Date issued . �_....7.... Application is hereby made to the San Joaquin Local Health District for a perr6it to construct and install the work herein described. This application is made in compliance with County Ordinance No', 549 and existing Rules and Regulations: C� JOB ADDRESS/LOCATION ' "? .................CENSUS TRACT .......................... Owner's Name =-=----------- ------------------------------------.................................... ...:................Phone ............... •---- Address ------ .�� . .......City Contractor's Name -- • - � .............:s.License #/13(��--*�-- Phone Installation will serve: Residence❑Apartment Houses] Commercial❑Trailer Court 0 Motel ❑Other.------......-------------------------,...... ��yy �- Number'of living units ...... Number of bedrooms ._._.r�.Garbage Grinder :...•....... Lot Size -• °---•--•..........................:... r Water Supply: Public System and name ------------------------------------------------- .............----------.....................----...Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt o Gay ❑ Peat❑ Sandy Loam Clay Loam ❑ Hardpan 0 Adobe t7 Fill Material ........4...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,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size... . .. .. . . ..�.._1.�.........:�--. Liquid Depth ....f .................... Capacity ` <-'Irk---.Typefength .*Material----C<71...... o. Compartments � Distance to nearest: Well . ..........................Foundation ..... Prop. Line ---........... ...... LEACHING LINE [ ] No. of Lines -----._.-.............. of each line_._........._...___._.... -- Total Length'D' Box _...:.:..... Type Filterial ....................Depth Filter M teriol ............................... ............ Distance to nearest: Well ____ __________________ Foundation _................ ...... Property Line ........................ SEEPAGE PIT [ } Depth .-•---- ----- ---- Diamet ---------------- Number ........... _.... Rock Filled Yes ❑ No {]�l Water Table Depth ...... ---•- .................................Rock Size --------- ............... Distance to nearest: Well -Foundation .- . _ Prop. Line ............. REPAIR/ADDITION IPrev. Sanitation Perm its# --_-_.-- ... _.•.......................... Date ................. ......,...... .,.) Septic Tank (Specify Requirements) !._....-----------•.....................•-------•........................-•-•---------....._.._.....----...,............. .. Disposal F41d, (Specify Requirements) 1. . rr )9 ..:�...CIV --`M.... (Draw existing and required addition on reverse side) t I hereby certify that I;.have prepared this application and that the work will be done in accordance with San Joaquin y County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health;District. Home owner or Ilcen- sed agents signature certifies the following: f "I certify that in the performance of the work for which this .permit is issued, I shall trot employ any person in such manner as to become subject to Workman's Compensation laws of California." 4 Signed __ - ------------- Owner 7 � �s �� BY ------------------- -- y ._......----- Title ................. -- ---------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. ,- -y-�---i-F-- `- ------- :�--2-------- •................ DATE �Z.'. �.7 -._..:..... = BUILDINGPERMIT ISSUED ------------------- ---------- ---�---------•---------------------------------- -------.DATE ------------------ ........................ ADDITIONAL. COMMENTS ------------------------------------ - - ------ ------------------------------------------------------ -=-------•--------.......--------------•----------------------•--- -------------------------------------- ....... ------------------------------------------ --------------------------------------------------------------- ......................... Final Inspection by: .. ._. ?-----•--------- .............................. .............-..............Date .�.................. EH 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT // 8/7h 3M x ��