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AOR OFFICE USE: 6 APPLICATION FOR SANITATION PERMIT ------------------------------------------- Permit No. _7 (Complete in Triplicate) L__�_�.�__. Date Issued _3_-/ -_7_Z_ _______________________________________________________ This Permit Expires 1 Year From Date Issued ;rte f? zf)o—d-0 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/LOCATIO --- -'?��--- S --t !��rc��-------CENSUS TRACT -------------------------- Owner's •- - -- Owner's Name ---------- ------- ------------------ --------- Phone _ AddressCity - ---------------- Contractor's Name __. __._ �-�_______----------License #oZC-Yl --- Phl6nre Installation will serve: "Residence ❑ Apartment House,[:] Commercial ATrailer Court ',❑ Motel ❑Other --------------------------------------------- Number of living units:___._ Number of bedrooms __ __,t_.___Garbage rinder __�___ Lot Size ---� a'<,.c�_--__-__- Water Supply: Public System and name ------- -- �� ------------------------------------------------•-----------Private ❑ Character of soil to a depth of 3 feet: Sand j( Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam Hardpan ❑ Adobe-[] Fill Material ------------ If yes,type _________________________ a (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: iNo septic tank or seepage pit permLitt�� public sewer,is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;f'] l'S r Size__ ______________________ _ Liquid Depth -------------------------- Capacity Capacity ------------=-----.: - Type -------------------- Material------- ----- ------ No. Compartments ----------------- Distance -----------Distance to nearest: Well ------------------------------------Foundation --------------------.- Prop. Line ----------------------- LEACHING ------LEACHING LINE . No. of Lines ____. ------------- Length of each line_____/0_a-__/---- Total Length -- ...... Q D'. Box ----/---- Type Filter Material _ _ ___Depth Filter Material ------1.9 --r f fit-- r Distance to nearest: Well �_ �_ Foundation-.____ Q_____________ Property Line ____ ____________._.___ �-SEEPAGE PIT Depth i _____ Rock Filled Yes No [ l p - - - --------- Diameter ----------'----- Number -- ------------------ - ❑ ❑ Water Table Depth ------------------------------------------------Rock Size ------------------------- ---- Distance to nearest: Well -----------------------------------------Foundation ----__ Prop. Line __________..____._ -------------- - REPAIR/ADDITION iPrev. Sanitation-Permit# ...._--------------------------------------- Date ---------------------------------- Septic __.______________..___.__._-._.__Se tic Tank (Specify-Reuirements --------- --------------------------------------------•------------------------- .<.---------- Disposal Field (Specify Requiremen#s) f` c ��" ;� ----�- Ac._. ' c/ ---------------------------------------------------------------------------------------------------------------- -- (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: "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 ----- ---- ---- Owner - ----------------By ------------ ----- ------ Title ------- (If other than owner) i 1 FO ..DEPARTMENT USE ONLY ---------------------------- DATE 4.7?1' - APPLICATION ACCEPTED BY ..-, --------- '- '�,P�--------------------------- - -- - ---------- k BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------- -------DATE ------------------------------------------- ADDITIONAL COMMENTS --------------- —_ �. .. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------- ------------------------------------------------------------------------------------------------------- -------------------------------------- p - = ------------- Final Ins- ection b = - Date .:�� ^��K Y J SAN JOAQUIN'LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev, 5M