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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----------------------------------------------- Permit No. �; (Complete in Triplicate) _'�_�_"-�.=_7. -------- - ----- /k 7 ' Date Issued --------------------------------------------------------- This Permit Expires 1 Year From 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 Count Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION --- ------ = --------------.. ``- CENSUS TRACT ��- ----Owner's Namee--- Phone =�C z . Address ----------- -------- �- _ _ City - --- ---•- --------------------------------•---- Contractor's Name ------------ -Z F�- -- r - ------.�—___4icense #47.77-`7--r--- Phone � z_P—_0_!. Installation will serve: Residence MApartment Hoouse,❑ Commercial ❑Trailer Court !❑ Motel ❑Other -------------------------------------------- 1 . Number of bedrooms Garbage Grinder - ..-_--_-._ Lot Size . ---------------- Water _-�C---- Numbe�r of living units:______f.__ �_____ g ! _Private Water Supply: Public System and name ----- ---------- -----•----------- -�--------- ---- - --- ---- ----------------------------------••--•---- ❑ 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 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 TREATMENTTANK SEPTIC S Size__________________________________ ____--------- [ ] [ ] i �� - Liquid Depth --------------------•-•--- T Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well ------------------------------------Foundation -------- ------------- Prop. Line ____.._--_----..______ r LEACHING LINE No. of Lines ___�_�____..___ .__. Length of each line.____._____- Total Length ___457�__�............... 'D' Box ._�.-__ Type Filter Material _R4�fC.Depth Filter Material ----/ . - - ---------------------- Distance to nearest: Well _ ' _ Foundation -------- Property Line ____sem .r.__._____ SEEPAGE PIT X Depth -- -------- Diameter4ZXJO-_. Number ------/----------------- Rock Filled Yes ` No i❑ Water Table Depth __,� _ -_ _ � - Roek Size -----------•--- --- r+ - - ...Foundation ___t---- -__-___ Prop. Line �___... . Distance to ne'a'rest: Well ------ _ ______ ________ ......- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_._-_________________ ___. -� �-n Septic Tank (Specify Requirements) �_ G' '-"' '`�— - Disposal Field {Specify equirements) -- ------- �' _____......� --�'�'�____ ______ ___ __ _______ £�_______- -- ----------------------- -------------- - ----------------------------- �.�. -------------- --- -- ---- ----------- --------- -- - ---------------------------------------------------------------------------------- -------------------- (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: "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." nA Signed ----- ------------------ - Owner ---------- ------- By ------------- � -- ---"-/- - --- Title -----<.�__ _— a__--------------- - (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ ----------------------------------- --------------------------------- DATE ------ --------------- BUILDING PERMIT ISSUED -------------------------------------------------------DATE -------------•----------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------- ------------------- --------------------------------------------------- - ------------------------------------------------------- ------ -------- ------------------------------------------- ------------------------------ --- -- _ ----- --------------- ------------------------------------------------------------------- ------------- - - ----- Final Inspection by //b� - - ---- -------•---------------------------------------Date --- SAN JOAQUIN LOCAL HEALTH DISTRICT, E. H. 9 1-'68 Rev. 5M ��'