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FOR OFFICE USE: �., APPLICATION FOR SANITATION PERMIT 7 � - Permit No. (Complete in Triplicate}.-- Date Issued _- Y _---_------------------- ------_------------__---_ This Permit Expires 1 Year From 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``compliancffe with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/L � OCATION ------- 0'v ---k� -------------------CENSUS TRACT -----------------------_ i Owner's Name ------- ------------ --------Phone Address �6-6----------jet�s{e�/u---------------------------------------------- Cityr ='�(`�r �' -----------------------------------_------ Contractor's Name -----�=�-- ---- �/ •. ------------------------License �y � __ Phone 4 ' Installation will serve: Residence [Apartment House❑ Commercial )]Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number of living units:------]---- Number of bedrooms ___..Garbage Grinder ------------ Lot Size ------------------------------------------- Water _______ _--____.____________----LM Water Supply: Public System and name --------------------------------------------------------------------------------------------.----•------------Private Character of soil to a depth of 3 feet: Sand'[ r Silt❑ Clay ❑ Peat ❑ 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 ------ Q Ca acit ------ Type ---------------- -- Material_______------ -------- No. Compartments ------------ Distance to nearest: Well --------------- --------------------Foun tion ---------------------- Prop. Line ---------------------- LEACHING LINE [ ] No. of Lines ________________________ Lengt of each line______ __-------_--._.______ Total Length ------------_ --__ D' Box ------------ Type Filter Mate al ____________________D th Filter Material --------------------.-----------------__---- Distance to nearest: Well _________ _____________ Foundat n .______.________-__ Property Line ________.___.-.___._.___ SEEPAGE PIT [ ] Depth ----- Diameter _______________ Numb r ---------------------------- Rock Filled Yes ❑ No if] Water Table Depth --------------- --------------------------------Rock Size -------------------------------- Distance to nearest: Well ______ _________________________________Foundation -------------------- Prop. Line __________.__--.-_____ REPAIR/ADDITION(Prev. Sanitation Permit d# ____________________________________________ Date ----------------------------------) Septic Tank (Specify Requirements) ----------------------------------------------------------------------------- ---------------------------- Disposal Fiel (Specify Requirements) _______ ' - ----------------------------------- - w dc s4 5 ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ` (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 Wor an's Compensation laws of California." Signed --------------- ----- ---�- -Q- Owner BY --- �f'' ......... v------- ----- ------------------- Title (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- - ------------------------------- ------- DATE ------ -------------- BUILDING PERMIT ISSUED ----------------------------------------------- ------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ------=------=--------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------_: _ _' = ------- Final by ----` ==` = Date = � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M