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� J FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -o r 3 7 / (Complete in Triplicate) - Permit No. --- ---------------- Date Issued ---------------------------_-- - This Permit Expires i Year From bate 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: 141 JOB ADDRESS/LOCA N ------ yo7 -- s CENSUS TRACT ---------------------- Owner's Name _____ _ _Phone __�/� — a 4 � 7 7 --------- ------ Address .4`- 0 ----I )---------------------------------- `�.�°City ---- Contractor's Name ---- --- ---- - --- -- 1 _-----.License # �,? 3�,/r'7, Phone - -_�_-_��' t Installation will serve: Residence`WApartment Housef] 'Commercial ❑Trailer Court ❑ # i { � Motel ❑ Other ------------- - ---- --• •----------•--- ' Number of livi+n units_____________ Number of bedrooms _-__--V.-Garbage a Grinder ______x._._ Lot Size _.___a�_________________.__________--__ Water Supply: Public System and.name _____-____--- _ °# ______________Private ❑ C Character of soil to a depth f 3 f ee t: ' Sand'❑) Silt C] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ IL t Hardpan ❑ Adobes' 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 TREATMENT { ] SEPTIC TANK'[ ] Size----------------------------------.------------ Liquid Depth ------ ---------- T Capacity ------- ------------ Type -------------------- Material---------------------- No. Compartments ------ ------- ... Distance to nearest: Well Foundation _____________I________ Prop. Line .___..._..... ........ LEACHING LINE [ j No' of Lines ------------------- Length of each line-----------------.---------- Total Length " ............ 'D' Box __::_______ Type Filter Material ------- ------------Depth Filter Material _____._____ Distance to nearest: Well ---------------___------ Foundation -Y--------------------- Property Line ___-_-_._._._-____.----- . SEEPAGE PIT'"[ ) Depth w___!�t---------- Diameter °_______________ Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth --------------------------------------- --------Rock Size -------------------------------- q. t Distance to nearest: Well ________________________________________Foundation _____________ ---- Prop. Line ____.___.._______-.._- -.REPAIR/ADDITION(Prev. Sanitation Permit# -------•----------------------------------- Date -----------------...........----.-I Septic Tank (Specify Requirements) ---------------------- --- - ---------------------- ` ,;Disposal Field (Specify Requirements) • ------------/------- e s --- --------------------------------------------------------------------------------- _ - -------------------------------------------=------------ (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 beco e s bject to Work n's Compensation laws of California." Signed ---__. -_.- - -----�'�`" Owner Title ----------------------------------- BY � ----------- ------- --- ----- ----- -- (If other than owner) R" OR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY---- ------ ----------------- ------------------------------------------------------ DATE -7- �-----71----- ------ BUILDING PERMIT ISSUED ------------------------� — - -------DATE -------------------- ADDITIONAL COMMENTS ______________._ - - _________________________________________________________________________________________________,._________----______- ...________._____________________________________________._____._.________._____- _ - ' . _ __.__________ __-____'___________-_________________ __________________________ _ _ _-_-_-Final Inspection by: - ------------------------ --------- --:---------------------------------Date Y7/ -------- SAN -------- SAN JOAQUIN LOCAL HEALTH DISTRICT k E. H. 9 1-'68 Rev. 5M