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{ FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT I1. :.T d Permit No: _7.5�'--��-. S {Complete in Triplicate} Date Issued --------- ------------------- [ Z 3 0 ---------------------------------- - ------- This Permit Expires 1 Year From Date Issued a ocal Hedlth District for a permit to construct and install the work herein Application is hereby made to the San Joaquin l described. This application is made in compliance with County Ordinance No 549 and existing. Rules and Regulations: JOB ADDRESS/LOCATION .--- ._____CENSUS TRACT ---------------- --------------------- Owner's Name _.__ �f .11 - !!1 -- ---Phone r / '' � --------------------------•--- City �1f _I -------------------------------------------•---- # Address -/-c 4 ------1E-- -- �y _ Contractor's Name _.-� -- ----�'�� -1--- -- I ----------------.license � Phone ' ��---- Installation will serve: Residence ❑ Apartment House-F1 Commercial ❑Trailer Court Motel [7 Other ------------------------------ ----------- Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------------------------------------- Water Supply: Public System and name ---- _________ ______ Private El- ----- - ------------------------------------------------------- Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay E] Peat❑ Sandy Loom -0 Clay Loam [I s 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.) No se tic.tank or seepage pit permitted if public sewer is a' ilable within 200 feet,) NEW INSTALLATION: ( P P E PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size---------------------------------- ------- ---- Liquid Depth --------------------,-- Ca acit - Type ----------- -- ----- Material------ ------- ------- No. Compartments ----------------- --------------- ---------------- Distance to nearest: Well ---------- -------------------------Founda on ---------------------- Prop. Line __-------------,------ ---- Total Length ------------- '---- LEACHING LINE { ] No. of lines ......�_________________ Len th of each line_________ __________.._ g ------•---- . D' Box Type Filter Ma vial -- Dept a Filter Material . Distance to nearest: Well __._.-- _ Foundation ----------------------- Property Line -.__----__-_-------_--_ tQ Diameter Rock Filled Yes Na SEEPAGE PIT [ ] Depth Number ❑ Q ---------------- 4 WaterTable Depth ------ ------- ---------------------------------Ro Size -------------------------------- Distance ------------------------------Distance to nearest: Well ---- _ -----F ation -------------------- Prop. Line---------------------- REPAIR/ADDITION(Prev. Sanitation Permit Y# ------- - -- ----------------------------- D e ----------------------------------) Septic Tank (Specify Requirements) --------- --------- ------------------------------------'----------------------------------------------- ----------------------------- Disposal Field (Specify Requirements) --- ---------------------------------- 411'1 ---'-�---- � ------------- = {Draw existing and required addition on reverse side) q I hereby certify that I have prepred 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 lice n. 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 Wor en's Compensation laws of California." Signed - Owner (��'� ------------------- Title If other than owner) L OR .DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY 1 DATE __ ._�Q'_ i-------- P ----------------- ------------------------------- - BUILDING PERMIT ISSUED -------------------- ----- - DATE i ADDITIONAL COMMENTS --------------------------- - -- ------------------------------------------------- -- t � --------------------- -------------- ----------------------------------------------------'----------------------------------------------s----------------------------------------------------------------------------------------------- C� �:1 ---------------------------------------- D - s-- em'---- � t t -------- -- ---- - - ------ Final Ins ection b SAN JOAQUIN LOCAL HEALTH DISTRICT t E. H. 9 1-'68 Rev. 5M L