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FOR OFFICE USE: `APPLICATION FOR SANITATION PERMIT 7 67S ---------------- - --- ------------------ ---- ____ ____� �` Permit No. _, (Complete in Triplicate) ------------ - ----------------------------- .____..____________________ ------------------------ 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 comp lance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . ___.� �_ - ----- - - - --- ----- - ---- --------------------CENSJ�JFACT ------------------------- Owner's -- - ---- ------------- Owner's Name -- fiF ------------------Phone ---------------------------------- Iu Address = / Contractor's Name ---------------------------------License - Installation will serve: Residence ❑ Apartment Ho"use❑ Commercial ❑Trailer Court ,[] Motel F]Other - � 4��- aat- ----- Number of living units:--- ------- Number of bedrooms ___ __._Garbage Grinder ________ Lot Size __ _____. Water Supply: Public System and name ------- ---- -- --------- ----- - ----- - ------- ------- •--- ----- -------------_- Private Character of soil to a depth of 3 feet: Sand k Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam F-1 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 Teverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size____ -�'� �j__-__,____ Liquid Depth ---------- �� 'cam- Material___rY�� "No. Com artment�, 'P__... �• Capacity 1sD____ Type p Distance to nearest: Well _ _�___ __________________Foundation �_ ________ Prop Line- `1� .. LEACHING LINE [ ] No. of Lines -.j_-. -_-_____ _ Length of each lined __ Total Length ,.Z2 ................ J C% ---------- -- 'D' Box ---t'------- Type Filter Material p�e Depth Filter Material _19__ ----------------_ ............. N Distance to nearest: Well ------------ Foundation _4_6 _____________ Property Line ,?__________ ________ SEEPAGE PIT [ ] Depth -------------------- Diameter ______ _________ Number _ ___.--____:____________ Rock Filled Yes '❑ No C] Water Table Depth ------------------------------------------------Rock Size Distance to nearest: Well _____ __________________________Foundation -------------------- Prop.-Line . .---.- REPAIR/ADDITION(Prev. Sanitation Permit# ___----------------------------------------- Date ---------------------------------- A-;V 0 Septic Tank (Specify Requirements) ----- ------------------------------------------------------------ ------------------------ �j. Disposal Field (Specify Requirements) - ------------------------- --------------- - ---- ---------- ---------- ---- --- ------ ------ �f ----- ----- ------- --------------------------------- ----------------------------- -------- - ------------------- - - ---- - ------- ------ Draw - - - - - ----------------------------------------------------------------------------------- (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 Sen Joaqui County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homeowner 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 Workman's Compensation laws of California." Signed - Owner By ----- _ V--'' :-2�' C- ( Title ------------- ------ ---------- - ------- ----- (If other than owner) - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ------------------------------------------------------ ----------------- DATE ----- 7`-71 (---------------...- BUILDING PERMIT ISSUED ------ ___ __.----------------------------------------------- _________.___DATE _-____-____. ----------------------------- ----------------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------•-------- ------------------------------------------------ -------------------------------------------------------------------------- ------------------------------------------ --------------------- ----------- FinalInspection by: ---- --- ---- ------- --------------•---•----------• -•-------- --------------------------------Date ------� t SAN JOAQUIN LOCAL HEALTH 'DISTRICT E. H. 9 1-'68 Rev. 5M