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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Permit No.._7q�-.. Date Issued 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/LOCATION ----- 74 . .... ...___.._CENSUS TRACT Owner's Name ...1,.J' - ---------------- -- --------Phone Address -7�T-� ._..__.,._�' - =°- Cit —E'- Contractor's Name ---rY B.License # Phone ......... .............. Installation will serve: Residence Apartment House❑ Commercial'❑Trailer Court I❑ Motel ❑ Other -------- ----------------------------------- 4umber of living units:.......... Number of bedrooms __.Garbage Grinder ---- Lot Size Water Supply: Public System and name .---------------------------- y ------------------- ------Private Character of soil to a depth of 3 feet: Sand'❑ Silt ❑ Clay E] Peat EJ 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 seep ge pit permitted ifublic sewer is available within 200 feet,) PACKAGE TREATMENT SEPTIC ••'y _ Liquid .Depth ,`. _ ------.------ No. CompartmentsTYpe Ca acitY Materia- ••-- Distance to nearest: Well ---------- ......... Foundation ------ 10_/------- Prop. Line ................ LEACHING LINE [1� No. of Lines _______ rJ- -____ Length of!each line_-------- 0. �...._..._ Total Length ._../w .__'_.._...__ 'D' Box _._._ __._. Type Filter Material _sJ,_ _...... Depth Filter Material ------- _...... Distance t nearest: Well ------a_ �_.____. Foundation...___ -1_a._ �_._._.___ 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 ..... ._............. .__...........) Septic Tank (Specify Requirements) ---- w ------ - - ------------........... - -------------------- ..... Disposal Field (Specify Requirements) . ......... .... .... ....... ..... .......... .................. .--------- ---------------------------- - - - In row 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 Wo, man's Compensation laws of California." Signed-------------------------------------- jy • � ^- ...... ----------- Owner - Y Title ----- ----------- ---------------- ----- •--------- --- ---------- (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �,.��,�r.+-1....�s.�e.I_�'------------------------------------------ --------------- DATE -�----�-�-..Z/ - ------------------- BUILDING PERMIT ISSUED -------- ----------------------------- ---- ---._._. _.---------- --.DATE -------------•-------------------•-------- ADDITIONAL COMMENTS .- -- --- --- -- -- -- -------- ------------ - - - - ---....._----------•----........... ------------------------ --------- ------- ... ...... .:------------------------------- ---------------- w ------------------------------------------------------------------------------------------------- Fina) Inspection by: --- - -- - --------------------------------------------Date `.1..li_ 71 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M