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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. __7_ __ .�-_-- --------------------- - -- --- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations:: JOB ADDRESS/LOCATION ..-- - Q ___. a� _..... _R-PART__-_W_1+- -- CENSUS TRACT, 11 Owner's Name -A qh-'-e-1-d----- -! = 1t !�j ` ---------------------------------------- _ ---- ------Phone Address -----P-,_-Alyllo1--- 1 � ' City �7 E✓' Y�`�� Contractor's Name ---41-_.�_,_-.. --------------------------------------License #--70'W -----_ Phone -* Installation will serve: Residence WApartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:-__---I_ Number of bedrooms _3----- Grinder ___------ Lot Size ------------ 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 _________________-____(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 _____--._________-___-___- Capacity -------------------- Type/__ ------ -- Material---- ------ No. Compartments ------ ............... Distance to nearest: Well -___ ___________________Fo ndation _---_________--____.- Prop. Line ____--_-_____;_-...--- LEACHING LINE [ ] No. of Lines --_--_---____-----_ h of each line- -------___-__-------- Total Length ---------------------------- 'D' Box _-.---_-__ Type Filter ___________________ epth Filter Material ___________--_-_____._._......._____..._.... Distance to nearest: Well ___ __________ Found tion ----.---________---_---_ Property Line ........................ SEEPAGE PIT [ ] Depth ---_-_--------___ Diamet ........... Nu er --_--_---------___-__--__ Rock Filled Yes © No i❑Water Table Depth ------------- ------------------ ------Rock Size -------------------------------- Distance to nearest: Well _____ ________________________•Foundation ____________________ Prop. Line ....___............... REPAIR/ADDITION(Prey. Sanitation Permit# ________---_ __-_-_-_____ Date __________________________________) Septic Tank (Specify'Requirements) - ------------------------------------------------------------------ -----------•---------------------------------------_-- DisposalFeld ( pecify. Requirements) ------------------------------------------------------------------x------------------------------ ---------------------------- (Draw existing and required addition on reverse side) 1 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: "1 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 orkman' ompensation laws of California." Signed ---- -------------- ------------------------------------- - -------------- Owner BY ----------- - -------- Title ------------- -------------------------- ------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------1 _i ---------------------------------------------------------------------------. DATE ----- BUILDING ---BUILDING PERMIT ISSUED ------------------------------------------------------------------------------------------ --------------DATE --------------------------------- ADDITIONAL COMMENTS ------------- -- - ----------------------------------------------------------------------------•------------------- -----------------=------------------ ------ ------- ---- - --------- ---------------------- --- -- --- - -- - - --- , ---- - -7-J--- Final Inspec --Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M