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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. 7-Z.~----__. -------------------------------------------------------- _________________________________________________________ This Permit Expires 1 Year From Date Issued Date Issued ___.�r.�.-.__.-.7v Application is hereby made to the San Joaquin Local Health District for a per 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 ._ _ _/Iy_o 41_ j __-_______-__CENSUS TRACT __ ` �__.._._.___. Owner's Name --------- -- -- ------------ ------- - - ------- -------------------------,----- / Phone ------------------------------------ Address --------------��49-- ----- 01----- •- - ---------- -- --. City -------! - .-------- -------------------- - ---- - --- - ---- - -------- GG Contractor's Name ------ - - ---- - --------- -License # _)o f-- ---- Phone ------------------------------ Installation will serve: Residence[T Apartment House❑ Commercial []Trailer Court i❑ Motel ❑Other -------------------------- ----------------- Number of living units:------J---- Number of bedrooms ____ ____Garbage Grinder ------------ Lot Size ____________________________________________ Water Supply: Public System and name ----------------------------------- ------------------------------------------------------------ ------------Private Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat El Sandy Loam Clay Loam ❑ 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT f ] SEPTIC TANK![ ] '. Size------------------------------------------------ Liquid Depth ----------_-----.--------- Capacity -------------------- Type --------------------'Material------------ --------- No. Compartments -----------._...------ Distance to nearest: Well _____________•_ ._______._Foundation ______________________ Prop. Line ._--_-____-_-_-.______ LEACHING LINE [ ] No. of Lines _ _________ Length of each line---------------------------- Total Length ------------------.------.__ 'D' Box ___________ Type Filter Material ____________________Depth Filter Material -------------------................_...___-_ Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ----_-----_-_-__._-___ SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ----- ---------------------- Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop. Line -------------- REPAIR/ADDITION(Prev. Sanitation Permit ----------------------------------- Date -------.-------------------------_I Septic Tank (Specify Requirements) -------------- - --------------- --------------------------- ----------------------- - ,..----------------------•--•- Ir D' osal Field (Specify Requirements) ----- --- --- -- - .� --- -----��` ------------------------------------ ---------- - -------- ------------- -- I_ o_a a. a —'---------L-tom? ------ - c - - --- ------- -------------------------------------------------------------------------------------------------------- nd-- w existing and equired 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: "1 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 ----- ---------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY --- - - ----------- DATE __�.'f' -��' " BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------- -------- -------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------ -- --- ------ ----------------------------------------------- ----- ------- - _V - Final Inspection by: ---- -.-- _ ,. A- Date -�-�- -_� -- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 1.