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FOR OFFICE USE: ' _ 7d' 'APPLICATION FOR SANITATION PERMIT ---------------- (Complete in Triplicate) Y------------------ _------------------ _--------- This Permit Expires 1 Year From Date Issued - Permit No: Date Issued'f -�_ __ 7a 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: 4c ____JOB ADDRESS%LOCATION � ----'--�-�--------------------------------- CENSUS T RACT ___1i ----------- s -- -- ----------- - oOwner' Address -- t�- "�+z't�'itl City i ------------------------------ -`-- Contractor's Name _ -t�•r �J --------------- License # i`5_V.Z•�%__:_ Phone _ 6_`3_ Z,- 'sem`' Installation will serve: Residence �partment House❑ Commercial: Court ❑ `� / Motel C] Other -------------------------------------------- Number of living units: -------- ---- Number of bedrooms �--- -/�- ---- Garbage Grinder ------------ Lot Size __71.4__________. Water Supply; Public System and name ___�r�_--/�/_ --------------------- ------------------------------------------------ Priv ate ❑ Character of soil to a depth ofr3 feet: Sand '❑ Silt ❑ Clay ❑ Peat ❑ 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 sptic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [ ] —ISEPTIC TANK.[ ] Size_______________________________________________ Liquid Depth ____________________-___•. Capacity -------------------- Type -------------------- Material ---------------------- No. Compartments - Distance to nearest: Well ------------- ----------------------- Foundation ______________________ Prop. Line _____________:_.______ LEACHING LINE [ ] No. of Lines ------------------ - z-- Length of each line -------'--_----------------- Total Length 'D' Box ----- ----- -- Type Filter.Materiai--------------------Depth Filter Material -------------- i:------------------_-------_-_ Distance to nearest: Well _____________ Foundation _______________________ Property Line. ------------------- SEEPAGE PIT [ ] Depth ____ Diametet ________________ Number -- ------- - Rock Filled Yes E] No Water Table Depth _-°-- ----------------------------------------- Rock Size --------------------------- i Distance to nearest: Well----------------------------------------Foundation-------------------- Prop. Line ---------------------- REPAIR/ADDITION (Prev. Sanitation Permit #____________________________________________ Date _______________ _-_.____________j Septic Tank (Specify Requirements)----------------------------- ---------------------- -- --------------- - - ! f � I Disposal Field (Specify Requireme ts) _Z54 _ ----- --�------ _--------_____ ;_ -� ------ ---- (Draw existing and required a itionon reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.' HdMe owner or licen- sed agents signature certifies the followings- "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--------------------------------- -- :'$Y ------------------------------------ "x (If other than owner) APPLICATION ACCEPTED BY --- BUILDING PERMIT ISSUED ______ ADDITIONAL COMM E T, --------- ----------------------------------- -- Final Inspection by: - ----- __ , E. H. 9 1-'68 Rev. 5M. --------------------------------------------- Owner --------------`---------- --------------------- Title ----------------------------------------------------------------------- t' ARTMENT USE ONLY ---------------------------------------------- - DATE --- �v% 0. ------ ----------------------------------------------------DATE------------------------------------------ _--------------------------------------------------------------- - ---------=--------------------------- ------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ` - - - --- Date ----- JOAQUIN LOCAL HEALTH DISTRICT