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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --------- --------- - (Complete in Triplicate) Permit No: _.7Z----------- This Permit Expires 1 Year From-Date Issued �I 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. 549 and existing Rules and Regulations- JOB ADDRESS/LOCATION .-- ®. --- -- �'-- d'"+ `------- �r CENSUS TRACT <-------------------"----- J Owner's Name i f rf7 ----------------------------•- ------------------------- -------------------Phone ------------------------------------ Address f� --- ----- _� )�i�"'---------------------------------------- City ` Contractor's Name -- f�.---=1> �? 1'--------------------- ----------License #/ --9�9_ Phone ---��1. Installation will serve. Residence E�<partment House,❑ Commercial ❑Trailer Court l❑ , Motel ❑Other -------------------------------------------- J Number of living units:_____,__ Number of bedrooms -c:.$-------Garbage GrinderE. Lot Size 1,e4fj_�e--- f_f________ Water Supply: Public System and name ________________ ----•-------------------------------•----------Private Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam. Hardpan ❑ Adobe ( ill Material ------------ If yes,type ---------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed-6n 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 Depth456015 ___________________ Capacity ------- TypeMaterial No. Compartments --a. .............. . Distance to nearest: Well �4151-------------------Foundation ` - -�----------------- -------- ---- Prop. Line � _ LEACHING LINE [Lr No. of Lines ------A---------------- Length of each --------------- Total Length _ - Lir .-____-_.-_ 'D' Box _o49, '_ Type Filter Material/ --- 0_1Depth Filter Material /0y__11-----------_----------------..----_ Dista n a to nearest: Well _Z_C;? ---------- Foundation _ - ----------- Property Line SEEPAGE PIT Depth ' '_ _____ Diameter _ ----- Number __.__._.^--------------- Rock Filled Yes " No ❑ Water Table Depth-f --------------------____ _--Rock Size I�ln_- ---___.___-_ --- � i f Distance to nearest: Well ___-, 10:____________________Foundation 1.;7197________ -Prop. Line _____._ t� REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------- Septic ______-____________________1Septic Tank (Specify Requirements) '4 Disposal Field (Specify Requirements) -------------- : --- ------------------------ --------------------- --------------------------------------- ---------------------------------------------------------------- i ------ -------------- ----- ---------------=------------------------ ------------ ------ ------- -`- --------------- --------------------------------------- -------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) k; 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 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." e Signed --- ----------------- Owner s BY - �� ------------------------------ Title (If of t�noner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. - - -----------------,---------------------------= '-` ,` -. DAT ------�_`_`S -7 BUILDING PERMIT ISSUED ------------------------ -------------------------------------DATE ------------------------------- ADDITIONAL COMMENTS ------ --------------------------------------------•-------•-------------------------- ---- -- "---------------------------------- --------------------------- ------------------- -------- -------------------------------------------------- --------------------------------------------------------- ------------------- ------ -------- - - - _ -- - _-._ n ------ - ---- -----__--__---------------'----------'--- ---------------------- --- - - ----- -- ---- Final Inspectioby: �/ --------------------------------------- ;-----------------------------.Date - =_7� SAN JOAQUIN .LOCAL HEALTH DISTRICT k . J E. H. 9 1-'68 Rev. 5M