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FSR OFFICE USE: APPLICATION FOR SANITATION PERMIT ,,!! -- -- ------ -- --="------ ------- ----------------- Permit No. _7.7-_" -- (Complete in.Triplicate) - ------- �- ---------------------------------------- ____________________________________________ _ _ Y This Permit Expires 1 Year From Date Issued ; Date Issued -4-_ ......... 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 - --------------- --.------CENSUS TRACT ------- OOwner's ,p � wner's Name -� ----[.r_'-- - ---------------- -- Phone Address �3 - ��,.J`�-�� --- - ---•_- - ------------ ---=-------------=-- City ----- License --------------------------- Installation ---_ - ---- -----------�---------------------------------- Contractor's Name _1 �- `'sem -- --- -- �"�� ------•---------.License #�. _-- �7 Phone Installation will serve: Residence'(Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- Number of living units:_.-------- Number of bedrooms ___:___Y_Garbage Grinder ------------ Lot Size _____ _ ____________ Water Supply: Public System and name ----------------------------------------- e,----------------------Private Character of soil to a depth of 3 feet: Sand tom" 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 TREATMENT [ ] SEPTIC TANK;[ ] Si e____________________________________.____ __ LiquidDepth _____________-._._-,___- Capacity _/(ff_4--_____ Type / _ _� Materia _ No. Compartments --- --_ Distance to nearest. Well ----------,��_C)---------------Foundation------- _________ Prop. Line ______L ________- LEACHING LINE [ ] No. of Lines -----/_.-------------- Length of each line--------TO------------ Total Length ------� '5;7v--------- �. 'D' Box Type Filter Material ---t_YL----Depth Filter Material _______t_ _____________ ______ Distance to nearest: Well ________________________ Foundation ________________________ Property Line ........................ SEEPAGE PIT [ ] Depth ___________________ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 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 Requirements) ----------------- ------------------------------------------------------•----------- -------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ JDraw existing and required addition on reverse side) 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 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 Workman's Compensation laws of California." Signed ----- --- -------------------- Owner By h r ----------------------------------------------------- T - Title .----------- -------- --------------------------------------- (I other than o ned FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------v --_- ---- --- ---------------. DATE -_-- -_-I--- 1- ------------ BUILDING PERMIT ISSUED ---------------------------- ------- -------- -------- DATE ------------- -------------------'-------- ADDITIONAL COMMENTS --- �— - s °'r �"'3- * ' E-cam.--n----------- ---------------- , °------------------------------------------------------------------------------------------------------- -------- ---------- - -- -------- -------- - -- - -- - ------------------- ---------- -------------------------------------------- ---------------- ------- -- ---- - - --- --------- ----------------------------------------------------------------- ------- -- --- -- - - - ]- Final Inspec ate -_ s SAN JOAQUIN LOCAL HEALTH DISTRICT -'i E. H. 9 1-'68 Rev. 5M