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• FOR flFFICf USE- C-7 sf: - APPLICATION FOR SANITATION PERMIT ------------ ` - �� (Complete in Triplicate) Permit No. 1� -------------- 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: 51R - . CENSUS TRACT ADDRESS/LOCATION --- --------- ----'- - .------- Owner's Name --------------- Address 'a -------------------------------------------------- - ------------------------------ City -- - _ --6 7 Contractor's Name ------------ -_�- --- ----- Installation will serve: Residency ;Apart4ntHouse❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ----------------------------------------- Number of living units:---I_------ Number of bedpooms ____ j----Garbage `GG_nrider _--___--__ Lot Size ______________________________________- Water Supply: Public System and name ------ _1---- --------------------Private ❑ Character of soil to a depth of 3 feet: Sand"[3Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ Adobe Fill Material ________ If yes,type ---------------------------- (Plot __ __ _________ _ _ ___(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 [ ] ze------------- �: A�_____________ Liquid Depth ------5_V_ ---------------- Distance s \ Capacity �.v _ Type _ _______ Material_ No. Compartments Distance to nearest: Well ------------------------------------Foundation -------------------- Prop. Line _________.____.______ LEACHING LINE ] No. of Lines ------------ ----------- Length of each line ---- ----------------- Total Length ---------________ 'Dkx ------------- Type Filter Material --------------------Depth Filter Material --------------------w--------- .. X11 Astance to tiearest:',Well -------------___ _______ Foundation ------------------------ Property Line _________._____ SEEPAGE PIT- Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No } Water Table Depth --- -<------------ --------------------------Rock Size -------------------------------- V Distant` _ an-est: Well _ _ __ ___________ _ ____ ,.___Foundation Prop. Line ______________________ rREPAIR/ADDITION(Prey. Sanitat' ` -------- __ Date ________-________________________) Septic Tangy (Spify Requ+ rrrents) - � 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, ancl 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, I shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----------------------- ------ --- -------- Owner -------- Title ---- --------BY - - r owner) FOR .DEPARTMENT USE ONLY 21110 APPLICATION ACCEPTED BY - - ------------------------------------------- ------------. DATE ---9 3 � --------------------- BUILDING PERMIT ISSUED _ _f___ _ ___ __ ___________ ___ __ ATE �1 -------- t AD TPNAL CO MENTS 'S ,F--- !t- W-0-7;0040- ___ _ - y - :- - - fit �: s ----- 2 , ------- �"-'------------------------------------------- - --------- ---------------------------------- ------ - - - - - -------------=------- --- ---------------- ----- - Final Inspection b _______________________Date _______ _ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M