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M r FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- Permit No. 7--I- 7--C�-"--7 i (Complete in Triplicate) t _-""-"___-- This Permit Expires 1 Year From Date Issued Date Issued --q-_Z'�- --------------------------- --[1 Application is hereby made to the San Joaquin Local Health District for a per 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 .y-�-'-- ?+�.±a-- - -- .-- --- - � 5--_CENSUS TRACT ' Name y � -�< Phone ----------------------------- Owner's Address O`--�1Q /l ----- ------ City -------- ------ o Contractor's Name ----- -- -- - ---------- --License # _�— Phone Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ❑ f ` r f Motel ❑ Other -------------------------------------------- i Number of living �units:-----I------ Number of bedrooms "____Garbage Grinder ------------ Lot Size .___.CL�u�-��y2-______. Water Supply: Public System and name ------=----------------------------- ------------------ ---------------------------- -------------------------Private Q� Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam -Er 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: fNo septic tank or seepage pit permitted if.public sewer is available within 200 feet,) d PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size---------------------------"----- "-- Liquid Depth ---------------- ----- Capacity --------- ------ Type -------------------- Material r—' ------ No. Compartments ----------------- Distance to nearest: Well ---_ -�------------Foundation ---------------------- Prop. Line ----------------------- LEACHING _-- _..___-__LEACHING LINE [ } No, of Lines ________________________ Length of each line---------------------------- Total Length ______-____-______________.. 'D' Box ----------.- Type Filter Material -________________-Depth Filter Material ___________________________________________ M Distance to nearest: Well __--_-___ ------------- Foundation ------------------------ Property Line. ---------.______-_.:.._. r SEEPAGE PIT .[ ] Depth -------------------- Diameter ---------------- Number ------------ --------------- Rock Filled Yes ❑ pr°No .0 I Water Table Depth ------------------------------------------------Rock Size "'------------------------------- ! Distance to nearest: Well _____ __________________________________Foundation -------------------- Prop. Line _______-__..__....__.. REPAIR ADDITION(Prev..Sanitation Permit ____________ ------------------------------- Date ____--______---_.____--___-.-.____ SepticTank (Specify Requirements) --- -----------------------------------------------------------------------------------•- ------------ -------------- Disposal Field (Specify Req irements) ` ------------ =--------- -------------------------- = ---------------------------- Q-p---'----- e ��------ ---�-- -- - ------------ ------------- - --------- ------------------- . 3 (Draw existing and required addition on reverse sid6l ) } 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 Son 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 nit employ any person in such manner as to become subject to Workman's Compensation laws of California."--- -- Signed -------- Owner Ti By ------------------------------------ -- n-- -- -- -------------- e (If other than owner) ! , FOR DEPARTMENT USE ONLY i ' 0 � 7 APA[.ICATION ACCEPTED BY ------- ------------------------------------ ----------------------------- DATE �� _ �' -------------r BUILDING PERMIT ISSUED ------ ------------------------------------------------- --------------------- --------- --------------DATE ------------- ---------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- j --------------------------------------------------------------------- -------------- ----------------------------------� ----------- ---------------------------------------------------------------------------------- ------ - - ...__.__. ..__ .. ,.-._._ _ a -- :- Final Inspection by: -_-- - ------------Date -----------_--- __--.f-- SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'68 Rev. 5M, +