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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - ------------------------------------ --------- -7-T—,330 (Complete in Triplicate) Permit No. ________________ ---------=---------------------------------------------- �\ Date Issued --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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 ._ -___ ,_- Z -- - CENSUS TRACT Owner's Na�1-�� c --------------------Phone ------------------------------------ Address -7-4 , c ' ' ,= ---- - ----- ---------•--. City ---------------------------------------- Contractor's Name _-- ____License # __ �' _ Phone ______________________________ Installation will serve: Residence Motel House❑ Commercial ❑Trailer Court f Motel ❑Other -------------------------------------------- Number of living units:------l----- 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 ❑ T Peat❑ Sandy LoamClay Loam E] 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) if PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size -- ------------------------ Liquid Depth ---_____---------_ Capacity -------------------- Type __ rMaterial------------------------- No. Compartments 1- 00 Distance to nearest: Well _____________________-__________--Foundation ---------------------- Prop. Line __--_--_--..._._....__ LEACHING LINE [ No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------.--_------------- m 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------._______ ----._-.-.----- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _____-_--.--..-.-------- SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No [3 Water Table Depth ------------------------------------------------Rock Size 0 Distance to nearest: Well ________________________________________Foundation _________._--.___. Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) _____________________________________ __ ---f �— / ------ Disposal Field (Specif Requirements) _ . ____ ____________________k=--r�- -�-��-- ----------- �----- - hY ------------ P---------- 7t - --- -------------------------------------------------------------------------------------------------------------- - - -------------------- --------------------------------------- ----------- (Draw existing and required addition on reverse side) 1 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: "1 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 la of California." Signed - j - Owner -- - -----• -- By -------------- ----- �r --- �. itle C 1 (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------------------------- DATE ........... BUILDING PERMIT ISSUED ----------------- -- ------------------------------------DATE --------- ----- ADDITIONALCOMMENTS -----------------------------------------------------------------------------------------------------------------------------------=--------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------ ---- -------------------------------------------- ------------------ -- ------ -- --------------------------------------------------------------------------------- --�^ a Final Inspection by: ------------------------------------------------------------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT jet__ E. H. 9 1-'68 Rev. 5M