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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT '' ---------- Permit No. _ 7l_--7�_5 (Complete in Triplicate) ------------------------------------------ This Permit Expires 1l 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 dinance No. 549 and existing Rules and Regulations: -----CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION ------------------ Owner's Name -!� Phone Address ------------------- Cit �r} l �.✓------------------ v Contractor's Name ------ - ------4 GO�-� ------- -----License #��----` --`---L- Phone �5----��-/� Installation will serve: Residence partment House,0 Commercial ❑Trailer Court ',❑ Motel ❑Other -------------------------------------------- Number of living units:-------)_ Number o bedropms ______Garbage Grinder G-s__ 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 'D Hardpan E] Adobe a ---------------------------- ' ill Materia l�d-- 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 [ I SEPTIC TANK [ S' e_______ -�C-------- Liquid Depth j -- ---- Capacity ____ _ Type _ Material_ o. Compartments -----2- .___.___ r— Distance to nearest: Well ------- ---------Fou dation _0.1,________ Prop. LineS—Z-------------- LEACHING LINE _No. of Lines --------- --------- Length of each line ----- Total Length -,� -f--------- / e 'D' Box __ 44Type Filter Material __��Depth Filter Material -- - -__-j____________________________ Distance _ nearest: Well _______________________ Foundation ---------- Property Line _ _______------ SEEPAGE PIT { Depth s_l_______ Diameter _3_ __ Number ---rD.,_____ --____�Roock Filled Yes �1 o�Q Water Table Depth ----- --------------------------------Rock Size ---,/ Zl _ Distance to nearest: Well _._________ - ----, -o-r___ Prop. Line .i?____/___._.____ REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------•-------- .--------------------------- DisposalField {Specify Requirements] ------------------------------------------------------------------------------------------------------------------------------------- ------------------ -------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- (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: "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 -------------------------------- --- --------------- Title ---- Q �� ---- ---------------- (If oche �owner FOR DEPARTMENT USE ONLY _ 23 7 APPLICATION ACCEPTED BY -�---- -------- ------------------------------------------------ DATE -------------- BUILDING PERMIT ISSUED ---- - ------------------------------------------- -------------------- ----DATE -- ---- ------------- - -- ADDITIONAL COMMENTS ---------------------------------- ------- - - --- ------------ ------------------------------------------------------------------------------------------- ------------ ------------------------------------------------------- ---------------------- ----------------------------------------------------------------------------------------------------------------- ------------------------------------- ------------ ---- --- -- - ----- ------- ------------ - - - - - - - ------ -- ----- - V Fi nal Inspection by: Date .. SAN J QUI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M