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FOR OFFICE USE: APPLICATION FOR SANITATION&MIT -� 6 Permit No. -__--_'-._-----.--7 7,437, ---- - (Complete in Triplicate) Date Issued ------- ------- =-- This Permit Ex ires 1 Year From'Date Issued - - -------------- P 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: Jed ------CENSUS TRACT ---- _----------- JOB ADDRESS/LOCATION _-} - ----- phone 5;1 7, b. ------------ Owner's Name A------- -- -- ---------- ------- ----------------------------------------- - ----- City Address - --- ------- -----5- Phone p - Contractor's Name ----------------- ---= --- ---------- --- - ----- ----- --- ---------- --------.License # /- Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court l❑ Motel ❑Other ------------------------------------------- Number of living units:----I----- Number of bedrooms ---3-_-.Garbage Grinder Lot Size ___-__-- ------ ----- - •-- - --- ------------------------------------Private , Water Supply: Public System an name --------------------------------------- ------------------- ----------- Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay El Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobe$1 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,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -------------------------- CapacitY -------------------- Type ------------- ------- Material---------------------- No. Compartments ------ --------------- Distance to nearest: Well Foundation __-___-__-_-_------ Prop. Line ------------- -------------- ------------------ LEACHING LINE [ ] No. of Lines ----------------------- Length of each line--__------------------------ Total Length --_-_--------------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•....................... Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ De Depth Diameter ---------------- Number _-___--------------- ----- Rock Filled Yes '❑ No 1❑ SEEPAGE PIT [ ] p ------------------ Water Table Depth -------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------•- 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 1 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: person in such manner "I certify that in the performance of the work for which this permit is issued, I shall not employ any as to become subject to Workman's Compensation laws of California." Signed ------ Owner --------------- --------6 --- -------- ------ --- --------------------- Title ---- --------------------------------------------- By ( f of er t owner) O ARTMENT USE ONLY APPLICATION ACCEPTED BY - --------------•---------------------------------------- DATE ------ ---------------- BUILDING PERMIT ISSUED --__-__ DATE __------------------------- ADDITIONAL COMMENTS ----- ------ -- -------------------------------------------- ------------------------------------------=---------------- --------- - --- ------------ ---- - --- - - - ------- --------- r; 1 f = -------------------------------------- -------------------------- --------------------- ----- ------ - - - ---- -- - — ------------ Date _.-� Final Inspection by: __- ----- --- - AQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M