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FO OFFICE USE: 7 . -I - - 57-,,-2 APPLICATION FOR SANITATION PERMIT - ------ - �,,3C1 (Complete in Triplicate) Permit No. ---------- - j� 1/-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: JOB ADDRESS/LOCATION 4 "' - +gt 1-700033 �I ------ - ------CENSUS TRACT - Owner's Name _-. --- ----- -�------ - ------------------------------ - ._Phone --- - ------------ --- Address 2�1 .� �o - - --------------- City - t ------ ------------ - Contractor's Name _____ -------- __ _ .LQ. ----- - _ __-----------License # s' /7.3_ Phone Installation will serve: ResidenceXApartment House❑ Commercial ❑Trailer Court :E]Motell �❑Other - - Number of living units:__-_ Number of bedro s _�______Go bq a Grinder ------------ Lot Size Water Supply: Public System and name ------------ - -- ----- ----- - - - - ----------------------------------------- -------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material _ _ If yes,type -------- ------ plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.)pf NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) p PACKAGE TREATMENT [ ) SEPTIC TANK[ Size------------------------------------------------_____________ Liquid Depth -------------------------- W ) Capacity -------------------- Type -------------------- Material---------------------- No. Compartments 1 Distance to nearest: Well ------------------------------------Foundation ____ ----------------- Prop. Line _________-______-_____ LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--------------_------------- Total Length _________ dr U J 'D' Box ________ Type Filter Material -__-___________-__Depth Filter Material -------------------------------------------- Distance to nearest: Well _________ ------------- Foundation ___________-__-_____ Property Line ______ J� ----------------- SEEPAGE PIT [ ) Depth ____-__________ Diameter _____________ _ Number ---------------------------- Rock Filled Yes L7 No _ Water Table Depth ------------------------------------------------Rock Size ----- Distance ---Distance to nearest: Well ---------------------------------------Foundation --------- ---------- Prop. Line .... ----------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date Septic Tank (Specify Requirements) ---------------- Disposal Field (Specify Requirements) d - - - - ------- ----- ----- ------- ------- -------- --- ---- s (Draw existi g 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: "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 ork n's Compensa ' n laws of California." Signed - ---=------------- Owner - ; _14- 10V By - - - - 1" ------- Title - ------------------------------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- ----------------------------------------------------------- --------- DATE BUILDING PERMIT ISSUED ----- --------------- ADDITIONAL COMMENTS ----------------- ------------ - - - DATE - --------------------------------------------------------------------------------------------------------------------------------- ---------------------------------- ---------- ------------------------------------------------------------------------------ -------- ------------------------------- ----------------------------- ---- - ------------------------------------------------------------------------------------ ------------- - - -Final Inspection by: ____ [_ -- -------------------------- - -------- - ----------- ------Date ----- -7 - - ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ` ,