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OFFICE USE: p APPLICATION FOR SANITATION PERMIT Permit No. -"7.3_----`�-•- IFOR ---------------- -------- - ------------ [Complete in Triplicate) -- --- - --------- - 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 County Ordinance No. 649 and existing Rules and Regulations: JOB ADDRESS/LOC _ �f___�Il.- ------CENSUS TRACT ------------ ----- Owner's Name ." !7%-2w—w Phone --------- -� .------- ------- - d- �.- ---------. City = ---------- ----------------- Address ---------- o - =-----.License # � -� ?hone ----------------------------- I Contractor's Name Installation will serve: Residen a Apartment House❑ Commercial :❑Trailer Court i❑ i Motel ❑ Other - ---------------------------- Number of living units;--- ------Number-of bedrooms ------------Garbage Grinder ------------ Lot Size ---- -� ` --Water Supply: Public System and name ------------------------------------ --------- --------- ----------•- - ------------------------------------Private Character of soil to a depth of 3 feet: Sand[] Silt ElClay E:] Peat El 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. ] Size-------------------------------------- -- - Liquid Depth -------------------------- PACKAGE ------------------- ----. w 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 -__________.--------•------------•---- - Foundation -------------------- Property Line. ------------------ SEEPAGE PIT to nearest: Well ______-__________�_- --- SEEPAGE PIT [ } Depth ________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No i❑ ----------------- Rock ---------------- Water Table Depth k Si -------------------------------- cl Distance to nearest: Well .____------------------------------ ---Foundation -------------- ---- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------•------} p Septic Tank (Specify Requirements) -------------------------- - - -------------------------- ------- ---- -- Qisposal Field (Sp ify quit — - - :---------------------- ------- -------- ------ ---------- •--- ----- - x - ,g tion and that-}� e (Draw existing and required addition on reverse side) I hereby certifythat I have prepared this application a 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." Signed ----------------------- -- - --- Ow ne - ------- ------- ------------------ - - - ---------------- ---------- 7it1e -------------------------------------- BY --------------- - - - - - ----- - --- (If other than owner) FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY -------- -- . --- ------ ---------------------------------------------- BUILDING PERMIT ISSUED ----- ----- --- - - ---------------------- ------------ ---- --------DATE ------------------------------------------- ADDITIONAL COMMENTS ---------------- -- --------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ------- ------ ---- ------ --------- - ----i+- - ----------' - ----- ---- --- ------- -- to i Final Inspection by: ---------.Da ---- _-" -- -- --`- --------= ----- - - -�--�- - ---� - --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT . 4 i F H 9 1-'68 Rev. 5M