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FC7R OFFECE USE: I LICATION FOR SANITATION PERM'S ------- --- Perini# No. ---------------------- (Complete in Triplicate) ________ M 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 compliant with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N ---� - _�_�F_ _.-- -------- -------CENSUS TRACT Owner's Name ��-� ✓ - .�GL - Phone i Address - .�--- ------ City = ------------------ -------- - Contractor's Name _ � ..�_ mol. �-� _ _ _�fsl------License # a V/23--- Phone Installation will serve: Residence ❑ Apartment House'❑ Commercial ❑Trailer Court! Motel ❑ Other ------------ ------------------------------- I Number of living units:______ Number of bed-rooms -----------_ arbage Grinder ------ Lot Size ._i`'S_ _ --------- Water Supply: Public System and nam - ----- --- -- ------------------------------------------`---•-----•------------Private' Character of soil to a depth of 3 feet: Sand'❑ Si It Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ AdobeX 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 [ ] Size------------------------------------------------ Liquid Depth ---------------------._--- d� Capacity -------------------- Type ------------------- Material---------------------- No. Compartments ------•------•- ------ ` Distance to nearest: Well __________________________________Foundation ---------------------- Prop. Line ..-.__________________ LEACHING LINE [ ] No. of Lines ___________ Length of each line ________________ Total Length ----------------- 'D' Box ------------ Type Filter Material _____-__-________Depth Filter Material ---------------------------_________________ Distance to nearest: Well _- ------ Foundation ------------------------ Property Line ________________-._-___ SEEPAGE PIT [ ] Depth -------------------- Diameter -1-------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ Water Table Depth -----------='------------- --------------------Rock Size ---------------------------•---- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------•___-- REPAIR/ADDITION(Prev. Sanitation Permit# ----------- ------------------------------- Date _________-___.___-__-_-_-___---•__} Septic Tank (Specify Requirements) -----------------------------------------------------------------•---•---------------------------------- Disposal Field (Specify Requirements) #--•ti- �� i rt ` - / �-� e �'________________ __ ____ _ r r --------------- X, S ---- ----- I------------------------- (Draw existing anc{ 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 "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 b ¢I e s bject to rkm Compensati avis of California. Signef ..�� -- -- -- --- Owner By ---------------------------- ..� .,, /r -------- Title .----------------------------------------------------------------------- (If other than o ner FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ __ DATE BUILDING PERMIT ISSUED ------------------------- �" ------ ------------- ----------------------------- DATE ---------------- ----------------- --------- ADDITIONALCOMMENTS ----------------------------------- f------------ ----------- --- ----------- ---------------------------- ----------------------------------- - ----------- - ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- t -------------- ----------- ------ ------------ ----------- ------------------------- ----- ------------------------------,�1-------- - - - ----------- -------- - --------------------------- ------------------ -------- - ---- Final Inspection by: ____ ___--.Date , -_ - -- -- - - ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9' 1-'68 Rev. 5M /