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FOR OFFICE USE: :.... ... APPLICATION FOR SANITATION PERMIT ............................... (Complete in Triplicate) Permit No. _..7. ..` ................... ................. / ....... This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 1 described.This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: lZ a // JOB ADDRE55/LOCATION .: .......:....-..___.._._:...---. ..._.. � _..... CENSUS TRACT ......._....._.._.,_.:.:.. ry -•.............. Owner's Name ........ . h ................... ... one ............ Address .-.._.._.L_.. _rr.l. ._.- �_... .. . ...:•..:............. City ...__ .._ Contractor's Name .._.. --- - License # .f .3 Phone .............................. I.` Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court a I; f' Motel ❑Other ...................... Number of living units------- Number of bedrooms ..__.'Garbage Grinder ------------ Lot Size -__.-rte. Water Supply: Public System and name .................. ..... ...............Private �Y . Character of soil to a depth of 3 feet: Sand❑ ilt❑ -Clay ❑ -Peat 0 Sandy Loam 0 Clay loam ❑ 4 ` Hardpan Adobe [] Fill Material ------------ If yes, type ...----------------- ___ (Plot plan, showing size of lot, location ofsystem 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 [ ] SEPTIC TANK f ] Size------........•---------------- ------ Liquid Depth .............•.._. ` t Capacity ----------- ... 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 � } Water Table Depth -----r=._:_�' �:: ___..••..............Rock Size ................. ... Distance to nearest: Well ........................................Foundation ........... ........ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........:...-----------,------------------- Date ) { Septic Tank (Specify Requirements) ................... ..... - 11................... •.............•--.....- Disposal Field (Specify,Requirements) ....... � _ - __..- _..__. `' .......... -•_.,�L.� ,r! 31 -----------•-- . ........ r ,•--� --------- ) . ................. ........................----------------------------------------------------------------------------------------------------------------------- F (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 ................ ............... :.. c _... .Title _...•----..... .......... (if other than owner) I FOR DEPARTMENT USE ONLY F APPLICATION ACCEPTED BY--- --•-- -- - - - t. DATE .. .�_ �.`: __...._ ._ . _. BUILDING PERMIT ISSUED ........................... . ----.......DATE ........................................... ADDITIONAL COMMENTS ........ .......... .........................A.- ......... -----------• ...................... ...............I.....•---....-_.... .c. -------------------------------•-••----•--•---- -...._. t._._ . Final Inspection b :�' Y �''�2°2 ef..- J.. ..................................... . ... .--- SAN JOAQUIN LOCAL' HEALTH DISTRICT �gCZ i E. H.13 24 1-'68 Rev. 5M .. �- 7 I-71) 1 u