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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------------------------------t Permit No: (Complete in Triplicate)-------------- --------7--------------- This Permit Expires T Year From Date Issued Hate 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 ---._-6_.iJ157-- ---- ---------- -----, moi _-% ____.cY---.------CENSUS TRACT -------------------------- -- - Owner's Name ....f, ----------------------- - ------ '------------------------ Phone Address ---- ------ ----------------- City --- ---- - -t!04--- --------------------------------------.._-.._...------ Contractor's Name ----6 -------__-&?4_1 -------.License # ?,,5W 7.3----_ Phone Installation will serve: ' Residence `Apartment House�❑ Commercial ❑Trailer Court Motel ❑ Other -- -------- ------------------ ._.... Number of living units:------ Number of bedrooms __ __-_-Garbage Grinder ----?----- Lot Size _-_ ___X 'Z Q -- ............... 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 ---------------------------- (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 TREATMENTs { ] SEPTIC TANK-NZ -°- _ Size__W&*'1S___ --------------- Liquid Depth ----��k------------ Capacityl��__Gf.-V-- Type No. Compartments -._- ...... 04 Distance to nearest: Well __________ rP-________________Foundation ---I_/.L*j_____--- Prop. Line ______ ate_____________ Length of each{ine_-4V__`_s`�_'__-_ Total Length LEACHING LINE j�(f No, of Lines ----------------------------- 10 n/-=t+1 " `D' Box --__/._----- Type Filter Material -S��.,e%0_____Depth Filter Material ------------ ... ............ S J . Distance to nearest. Well ,_:_: 4_---_______ Foundation _.___/ __'_____--_ Property Line, ------- ---------------- SEEPAGE -_____ ___ ____________SEEPAGE PIT [ ] Depth --------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ - No ❑ Water Table Depth -----------------------------------------------.Rock Size -------------------------------- Di stance ------------------------Distance to nearest: Wel! --__--___71------------------ __*_____Foundation ------------ ------- Prop. Line ---------------------- REPAIR/ADbITION(Prev. Sanitation Permit# -------- --------------------------- Date:---�-----------f-----------------1 Septic Tank (Specify Requirements) -------------=-y---------------------°----'------------------- ------ --------------------------------- Disposal Field (Specify Requirements) ----------- --------- - ----------------------------------------------- ----------- f __________________________________________________________________________________________________________________________________________________________________________________________________________ (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and.that 1 the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin LocaltHealth District. Home owner or licen- sed agents signature certifies the following: I "1 certify that in the performance of the work for which this'p6mit Wissued, 1 shall not employ any person in such manner as to become subject to W rkman's Compensation laws of California." Signed - ----- i--------------------- Owner BY ---------------_. --- - ---- Title (if other than owner) 5 FOR DEPARTMENT USE ONL r APPLICATION ACCEPTED BY ------- DATE _ /�- l� ----- -------- ---- BUILDING PERMIT ISSUED - ---- -------t ---- --DATE _.. �_ ADDITIONAL COMMENTS ---- ---'---------------- --------------------------------------- -r F_. - ----- ------------------------ ----- --------------------- - '------------------------------------------------------ - - -------------------- ----------=------- Final Inspection by -= ----------------------------------- = �=�� f .-Date --- SAN JOAQUIN LOCAL HEALTH RICT E. H. 9 1-'b8 Rev. 5M