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FOR OFFICE USE: --- ----- ------ --------- APPLICATION FOR SANITATION PERMIT 7 7 8 3 Permit No. - ------------------- (Complete in Triplicate) ----------------- - - -------------------------- p �``--``- --- Date Issued -CJ-_--�=-G � ______--_____ ---4� �___ ----- --------------- This Permit Expires 1 Year From 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 ----------------------------------------------------------CENSUS TRACT ------ ------------------- Owner's Name_---W,_\- �� "z � - Phone 5 �� Address - r �1� --------------------------- ------------------------------------------------•. City _\ lC= - Contractor's Name _�------- --------------------------- -------------------.License # ------------ ----------- Phone ---------------------•-------- Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court I❑ Motel NrOther ----L�4-_ ______________ Number of living units:_-_ _-__ Number of bedrooms ---4------Garbage Grinder -- '___ Lot Size AS --M')=�4__________________ Water Supply: Public System and name ------------------------------------------------------- ----------------------- c_�1'��.----------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 ---------.____________-___ \ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) '4 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[v]' Size------------------.------------------------------ Liquid Depth -------_________________ O ,. Capacity - �oo CA\Type PAW"_'NS: -__ Material� �-_________________ S ,,,ee Kms, Ni_� C ___ No. Compartments Distance to nearest: Well �� _ Foundation ___VD�___ _____ Prop. Line _& � LEACHING LINE [ ] No. of Line__ _______________ Length of each line-------CI-0-------------- Total Length ,___ �. ............... D' Box __.v______ Type Filter Material 901A,Depth--Filter Material ______t___®_____________________________ Distance to nearest: Well ________________________ Foundation _________ Property Line -___________-_.-__...___ 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) ------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------- (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: "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 b o -ubjec ork 's Compensation laws of California." Signed 2_ ----- � ' � Owner BY ------------------------------------------------------------------------------------------------------ Title --------- ----------- (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- - -------- ---------------------------------------------------------------------. DATE ---- ----------------- BUILDING PERMIT ISSUED __ ----------------------------------------------------- -------------DATE - ------ - ------------------------ ADDITIONAL COMMENTS ----------------------------------------------------------------------------------- - ----- ---- --------- 1------- - �------ - - - ------------------------------------- r ---------------------------------------------------------------------------------------------------------------- -- -- -- - --------------------------- - - - - ------ _ - - --- ' �1 __ - -------- ------------ Inspection by: - `A- ------------ Final Date SAN JOAQUIN LOCAL LLTH DISTRICT E. H. 9 1•'68 Rev. 5M CO