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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - (Complete in Triplicate) Permit No. ------- -------- ----------- --------------___ ---__ This Permit Expires i Year From Date Issued Date Issued r 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/LOCAT N 7 [, ---.�cc.}s--c,u J7 . --------- ---- ---------------CENSUS TRACT ------------ ---•-- Owner's Name - ----- - ------- Phone ----------Address ------------ ----------- CitY Contractor's Name Phone ---- -- ------- --- --- ------- -- ----- --- License Installation will serve: ResidenceApartment House E] Commercial :❑Trailet Court ;❑ �.. # Motel ❑ Other - ------ -T---------------- Number -------------Number of living units:-----1----- Number of bedrooms J-------Garbage Grinder ------------ LotSize <- --� - Water Supply: Public System and name ------------------.------------------------------------------ ----- ------------------- - Private - - Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay El Peat El Sandy Loam --------Clay Loam Hardpan ❑ Adobe [] Fill Material ------------ If yes,type ............................ (Plot 'plan, showing 'size of fat, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seenane pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT i [ ] SEPTIC TANK [ Size_ � •�_�__ -- ----------- Liquid Depth _��---------------------. V Capacity _1 d-- Type -�---`-:ems Material_____- �` '-_�-. No. Compartments ----_--------- ---------- -_ . __ Distance to nearest: Well i Foundation __. f Prop. Line LEACHING LINE [+f No. of Lines - -- �-�- ---____-- Length_of .each line-----�U_--------------- Total Length __�_-`�0_..-_:--_-__-- I D' Box __---- Type Filter Material ____ _:_5f -- _Depth'-F:Y& Material _-__.�__1-------- _ _ _ .- Distance nearest: Well __------ _--_--___ Foundation _r_ _---_____ Property Line ----- SEEPAGE ` = SEEPAGE PIT [ ] Depth -------t------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No —�, Water Table Depthi----------------------------- -----Rock Size Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------- REPAIR/ADDITION --------_------ --REPAIR/ADDITION(Prev. Sanitation Permit# -•--------------- ------------ Date -----------------____-- - _ Se ptic Tank fSp{cP.y R�uirgmentsl -------------------------------------------- j Disposal Field'S ecif Requirements) ----------------------------------------------------------- --------------------------------------------- - ------------------------------------------ ----------------------------------------------------------- ---------- ------------------•----------- ------=-------------------------------------------------------------------------------------•------- (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 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: a "I certify that in the performance of the work for which this permit is issued, i shall not employ any person in such manner I as to become subject to-W man's Compensation laws of California." Signed -------------- f Owner i -� BY ------- ,e =� - =� Title ' -------------- -- ---- -(If other than owned FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ - -----------------------_-- BUILDING PERMIT ISSUED -------------- -- - -- DATE -�--- ------------------ DATE ------------------------------------------- ADDITIONAL ------- --------- COMMENTS ------------------ --------- -- - -------� - - -------------- - ---------------------------------•---------------------------------------------- --------- ----- ._f ------------------ ------- ------------ ----------------------- ----- ---- ------- -r °----- ----C_LA------- - -- --------------------------------------------------------------------- -- ----- ina Inspection by: -- -- _ - =------ - Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 1