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FOR OFFICE USE: � 3 APPLICATION FOR SANITATION PERMIT C� -------------- ------------------------ ----- Permit No: ._7-2, ___ - (Complete in Triplicate) ---_ This Permit Expires 1 Year From Date Issued Date Issued _._ ."____...7.. ftliccion 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 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION - -- _ - -a �'--- -- ---- - ------------------------CENSUS TRACT -------------------------- Owner's Name -- -- --- -----� ---------------------- -----------Phone ------------------------------------ Address __�;� + girl G�-- ---------------------------------------------------------------•--. City,e'zr,/�'7 ---------------- Contractor's Name ---- � �-c- ,e. -----------------------------.License # _ Phone = •-� Installation will serve: ResidenceApartment House ❑ Commercial ❑Trailer Court ;❑ / Motel ❑Other -------------------------------------------- Number of living units:__L-__---- Number of bedrooms.. ------Garbage Grinder Ae_ Lot Size _�?�F-01'-�_____________ � Water Supply: Public System and name _____________ L/ __________________Private` Character of soil to a depth of 3 feet: Sand' Silt Clay Peat Sand Loam Clay Loam' I p ❑ ❑ Y �❑ ❑ Y ❑ Y Hardpan ❑ Adobe-E] 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.) a. N NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer'is available within 200 feet,) , 1 PACKAGE TREATMENT [ } SEPTIC TANK{ ] Size-----------------------------u.,------------------ Liquid LDepth -- ------------------------ Capacity -------- Ca acitY --- -- -- -- - Type -------------------- Material_______ ' -No. Compartments -------------- ....... O. Distance to nearest: Well ------------------------------------Foundation _.. ___ ___ Prop. Line ________________._._ i 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 -. . _- ____SEEPAGE PIT [ j Depth ___________________ Diameter ________________ Number ____:.__.__._._______:-_`•., Rock Filled Yes ❑ No .❑ J `i Water Table Depth ------------------------------------------------Rock Size '-------------=---•--------- Distance to nearest: Well ________________________________________Foundation --------------- Prop. Line _-_-_____-______.___.. REPAIR/ADDITION(Prey. Sanitation Permit# ____________________________________________ Date----------------------------------- Septic ___________'____________________Septic Tank (Specify Requirements) ----------- -----------= - �/ - ------------------------ Dis osal Field (Specify Requirements) 5 ,� ______ -a__4r-__ ------------------------------------------------------------------------------------------ ---------------- ----------------------------------- --- ----- --- ------- ---- - -------------- --------------------------------,-:--------=-------- --------------------------------------------- {Draw existing and required addition on reverse side) ` I hereby certify that I have prepared this applicationand-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 r BY ------------ Title � . (If other than owner) f F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------------------- DATE__ - 5-9-a------------------- BUILDING PERMIT ISSUED __________ ---------------------------------------DATE ---�____` : ._ -._--------------------- ----------------------------------------------------------------------- ADDITIONAL COMMENTS ----- _=�--------------------------------- � L 'o ..---- — ----- --------------------------------------- - ----------------------------------------------------- --------------------------------------------- t --------------------------------- ---- y } Final Inspection by: --- ---- ----------------- = - ----------------------------Date ----_--� c -------------- SAN JOAQUIN- LOCAL HEALTH DISTRICT E.-H. 9 1-'68 Rev. 5M G