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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIt // --------------------------------------------------------- Permit No. 4-7-1 (Complete in Triplicate) __________________________________________________ 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.419 and existing Rules and Regulations: JOB JOB ADDRESS/LOCATION . _, 3 _ _' ___x__ ----------------- _��- - �---_._ _�ENSUS TRACT .____ � ----------------- Owner's Name e if Y-------- ` -----------Phone --- - Address _ - --- ------- ------------ ----- --------=�'`�'+ �J -'-�---� --�L �.k. �,._,._- ------------ - . City �`�-��=�-�'=-�=--�=-- -- - Contractor's Name _. _i ------- Installation �- _ t « -------------------------.License # �2--?Phone __ ._c'----- 0 Installation will serve: Residence partment House,❑ Commercial❑Trailer Court [I Motel ❑Other ------------------------------------------- Number of living units:________ Number of bedrooms- ......Garbage Grinder --,,K Lot Size _._ ___-ac-a__________-_-... Water Supply: Public System and name ---------------------- -------- - - ------Private Character of soil to a depth of 3 feet: San Silt❑ 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 tic tank or seepa pit permitted if public sewer iisvailable within 200 feet,) PACKAGE TREATME SEPTIC TANK." Size_.__ _ Liquid Depth ____. l? I •- Ca Capacity '_( _ Type _ _ --'_C Material_ x__ L ____ No. Compartments i"J P Y Yp Distance to nearest: Well -___________________Foundation -_A___(------.___prop.Line ............ LEACHING LINE L/gam`^J No. of Lines _.____ Length of each line-___ C_` =:_ <'` Total Length ! ------'_ - - - --- __ - _ Xto D' Box __'_+1 _ Type Filter Material �_!?_.- `"' Depth Filter Material ____ _________________ l 1 / f Distance to nearest: Well __ .( ______ _____ Foundation ___ _---______________ Property Line ---L----------------- SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number _____________ ----------- Rock Filled Yes '❑ No i❑ 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) -_---_______ _______________________ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ ---- ------- -- ---------------------f-- -------- ------- ---------- ---- -- - - - ------------------------------------------------- --- --- - - - ------- (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 Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "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 ---- --- -- - ---------- --------- Title ----------------------------------- (If - - other than owner) �}— FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------l---L-R- 1----------------------------------------------------------- ------------------ DATE ----- - - 1! BUILDINGPERMIT ISSUED ------------------- ----------------------------- --------------------------------------------------------DATE ------------- ----------------------------- ADDITIONAL COMMENTS ___ ��' -------------------------- ----------- ------------------------- --------------------------------------------------=--------------- ---------- ------------------------------------ ---- -- - ---------------- - ---- ------- - --- - - - - - -------------------------- -- -- - ---------------------------------------- ------- ------ - - -- ----- -- - ------ -- -- - li- Final Ins __.___Date ..__ __ ___ p SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M