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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No.7/7_71-- 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 my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . �� '±z' Y1`�'EENSUS TRACT ---- - i. 1 Owner's Name ley '� i-0-0-k- S-----------•--------------------------------------------- ---Phone 0� Address -------- --�0_(0_Q2---------S------ L ---------------- City 5 ---' Contractor's Name -- -------------------------------------------------------------------------- -=--------License # ------- ------ Phone ----------------------- Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other -------------------------------------------- p�- Number of I`ivmg units:----i------ .G _ Number of bedrooms _1P_____Garbage rinder LktA V - Lot Size ___ _Q _�f- ___ _C� . -.____ c. - `i. Water Supply: Public System and name ----------------------------------------------------------------------------------------------•-- ------Private U/ Character of soil to a depth of 3 feet . Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy ,Loam❑ Clay Loam n Ha`rdpan Adobe'Di 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.) rQ NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewers.is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK M," Size_____ '?_r..2�_��?_� r'. __-_____-___-; Liquid/Depth ___---_______________- _t Capacity\+ _ Type ST_ Material______ {-i -.__ No. Compartments --- L---------- Distance to nearest: Well _________________________________ -foundation ------------ Prop.Prop. Line ._.._________:________ LEACHING LINE [ ] No. of Lines ---;-________________ Length of each line-- ' ''-_-___Notal: Length ----1-�e--------------- 'D' - - - --------- �...ff�te�9� 4 b' Box ___ _.._ Type Filter Material SeP"x,_ .-Depth Filter Material �g��__-___._._- _ --- Distance to nearest: Well ____�OO� -------------- .______-__ Foundation n �______-____ Property Line ________________ SEEPAGE PIT [ ] Depth _tP*----------- Diameter HA,&______ Number ------;9------------------ Rock Filled Yes j" No i❑': St7MP-& Water Table Depth ---i-oc(k--------------------------------Rock Size 'n�--------------------- Distance ---------------- --Distance to nearest: Well A �-------______________-----Foundation -- 5-_` __.____ Pro Line __ ....__.__..-- REPAIR/ADDITION(Prev. Sanitation Permit.# -------U--------------------------------- Date ------------------------_......... ) i d �' Septic Tank (Specify Requirements) ---------------- -------•- '�-------------------------------------------------- ---------•- �, .-..... Disposal Field (Specify Requirements) ------------ ----- ----------------------------------------------------------------- -.--; --�:-----------------...... .a.t a. , } -----------------------------------------------------------------------------C--- ------------------------------------------------------------------- - i ----------_-------- ----------- : i (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 SariJ_oaquin County Ordinances, State Laws, and Rules and-Regulations of the San Joaquin Local Health rMi rict. Home owner or licen- sed agents-signature certifies the following:,, i, , . s i�; "I certify that in the performance of the work`for which this permit is issued, I shall not employ any•person"in such mcnner as to become subje W n's Compensation;laws of California." ��,- .lu .� Signed - -- --------------------------------- Owner 4 -• By-------------- ------------------------------ -- ---- ------------------------------------ - ----- ;title ----------------------- -- ------------- -------------------- (If other than ow r) Al �— FOR DEPARTMENT USE ONLY ° s APPLICATION ACCEPTED BY --------------------------------------------------------------------------- DATE ----- PERMIT ISSUED ---- --------- --------------DATE -------------.---_------ ----------------------------------------------------------------------- ------------------- ADDITIONALCOMMENTS ----------------------------------------------------------------------- --- -------------------------------- ------ ----------------•- --------- -------------------------------------------------------------- ---------------------------=---------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- - - Final Inspection by: ---------- date , i, --- -- -- --------------------- ----- --------------- --------- r at -------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.'9 1-'6$ Rev. 5M 1