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i i FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7I--S ------------------------------------ - (Complete in Triplicate) x ------------------------- p Issued Date Issued --- IVI.2 This Permit Expires 1 Year Froin Date --------- -------------------------------------- --- - - - Application is hereby made to the Son Joaquin Local,Health District fort' a permit to construct and install the work herein described. This application is made in compliance with,County Ordinal ce No. 549 and existing Rules and Regulations: T JOB ADDRESS/LOCATION S �!- - � 1 - CENSUS TRACT t - Phone ----------------------- Owner's Name ----------------------- �`�� --- dl ! {sem" /� G City Address ------------ -�� ----/� �--�. --- r / - .License # r� �Phones�-�, I Contractor's Name.----- `� it Installation will serve:, Residence partment House❑ Commercial ❑Trailer Court 0 •, , W Motel ❑Other - -------------------- -----?-------------- f Number of living units:-. "- -- Nu^tuber of bedrooms "�---GarbagJGrinder /"�"�/�---- Lot Size --""/- ��- � `� -- /r M i u�.,. Water Supply: Public System and name - - Prwate ❑ '�.. Character of soil to a depth of 3,feet. a Sand'[] Silt❑ Clay E] Peat ❑ Sandy loam -❑ Clay Loam ❑ Hardpan E] Adobe Fill.Material ------------ If yes„type ---------------------------- F (Plot plan, showing size of lot, location of syste�m;.in relation to' welyls, buildings, etc.;must be placed on reverse side.) pd NEW INSTALLATION: (No septictankor seepage pit permitted if puiblic sewer is available within 200 feet,) .r PACKAGE= TREATMENT [ ] SEPTIC TANK'[,l].>- Size--------"_-1�--------- Liquid Depth ----------- ---------. . ------ -No.` Compartments ------- --------- CapacltY --------- Type Material Distance to nearest: Well -----------------------"-----1I-----Foundation --------- ------------ Prop. Line --------------- ----- ! LEACHING LINE [ ] No. of Lines ------------------------ Length of each 1�line- ---------------------`---- Total Length -----------•---------------- D' Box "ry"" -- Type Filter Material -------------�`------Depth Filter Material -------------------------------•------------ Distance to nearest: Well -------------------- --- Fou dation ----------------�-- Property Line --------------'-- ------ ; Rock Filled Yes ❑ No 0 SEEPAGE PIT [ ] Depth ------i 1------ --- Diameter ---------------- Number WaterTable Depth ------------------------------------------------� Rock Size --------------- ------- i I Distance to nearest: Well ---------------------------------- Date ___-"_ -" 1 l� - ---- ---------- Septic Tank {Specify Requirements) ' 1 � Disposal Field (Specify Requirements) -----__---- _ { -- ---------------------------- ---- II� ----------------- ----',------ ------------- - t ----------------------------------- ------------------- ------------------------------------ -------- ------------:. ----- ------------ (Draw existing and required additi`n 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: I "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 Compen Cion laws of California. Signed - ----------- ----- OwneriBy "� Title -" ��'� --------------- ------------- (If of than owner) �' FOR DEPARTMENT USE ONLY 'APPLICATION ACCEPTED BY -- - --- -- - -------- ------------------ ------------- DATE BUILDING PERMIT ISSUED ------- - --------------- -------- --`------- ----------------------------- $ DATE - ---------------------------- ADDITIONAL COMMENTS -------`- •----------- ---- ------------------------------------------------ ------------------------------------------------ ------ --------------------------------- --- --------------------------------- ----------------------- ------------------------------ ------- - ------------------- _ _______________ ---- -------Date ------- ------------------------------------ F -------------------------------------------- inal Inspection by: - "-----------------" y �l` g i SAN JOAQUIN LOCAL HEALTH DISTRICT L.1� F. H. 9 1-'68 Rev. 5M �l ”"