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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT permit No. -'7 ---------- (Complete in Triplicate) ------------ --------------------------- ------------=--- 1. _________________________________________------------1_1 This Permit Expires 1 Year From bate 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 .;--—- ------ ------------------------- -------------------- ----- ------CENSUS TRACT -------------------------- _ _ POwner's Name -------f/----- U ' ------------------------------ ------- --Phone1a_- '� 19 __ AqAddress ----- �r Eh'-r------ --�� ---------- City 's Contractor's Name .__ ,.Cr-_I` _/_-`P License 7_____ 7 _____ ________ Phone __-_.__ __ �"�� >� #'z`fr y/ ��c3~ -9::7_ --- Installation will serve. Residence ('Apartment House❑ Commercial :[]Trailer Court ',❑ Motel ❑Other -------------------------------------------- Number of living units:------ Number of bedrooms------Garbage Grinder ------------ Lot Size -------------------------------------------- Water ________________________________________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 ---------------------- ----- v (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 [ ] Size------------ ------------------ --------------- Liquid Depth ----------------_--------- Capacity -------------------- Type -------------------- M erial----------- -:-------- No. Compartments -------_ -• ------ Distance to nearest: Well ---------------------- -------.--,-.Fou ation ------- -------------- Prop. Line ......._.------------- LEACHING LINE [ ] No.11of Lines ________________________ Length o each line--- _--____._____-- ------- Total Length --__.__________--_--_-_----- 'D' Box ------------ Type Filter Materia ------------------- epth Filter Material ---------------------------------------.- �i Distance to nearest: Well ___________ __________ Foun ation ----------------------- Property Line __-_____-.__.__-__-..... SEEPAGE PIT _______._____ Rock Filled Yes ❑ No [ 1 Depth ------------- ------ Dia'mete� tuber . Water Table Depth ----------- -------------------- -------------Rock Size -------------------------------- Distance to nearest: Well --------------------- ------------------Foundation ------ Prop. Line --------.__-..-----_.- REPAIR/ADDITION(Prev. Sani)itation Permit# - ----•--------------- ------------------- Date ----------------------------------) Septic Tank (Specify Requirements) q = --------------------- --------------------------------------------------------------: --- -------------I—— Disposal Field (Specify Requirements) ___________ ______ - ---------- ----------- - --------------- -- --- = ------------------------------------------------------- - '' (Draw existing and required addition on reverse side! is 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. Rome 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 ompensation laws of California." Signed ------ ---- ----------- ----- ---- --------------------------------------- ------------ Owner B --- -- (If other than owner) -------- Title I! O DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'...---------- - ----------- ---- ----- ------------------------ ----- ------------------------- DATE ---------- BUILDINGPERMIT ISSUED ---------------------------------------------------------------------=-------- ---------------------------DATE ----------------------------------------- ADDITIONAL COMMENTS ----`i = I� - ----------------------------------------- ---------------------------------------------------------------------------------------------------- -------- ---------------------------------------- -------- ----------------------------------------------------------------------------------------------------------- . . -------------------L------------------------------ Final Inspection b Date __. y --------------------- --------------------- ------------ '� SAN JOAQUIN LOCAL HEALTH DISTRICT li E. H. 9 1-'68 Rev. 5M II