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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7` ...................11..................... (Complete in Triplicate) /Jf ..........I.............................................. -7 Dote Issued ............................... 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..... .. ...... .... ........................ ....................... ---CENSUS TRACT .......................... 1'�". 4. 1............ .._-Phone 34f R-key� ............. Owner's Name . - Al 11&�_ ,-- ----- -------------------:_ city .4��---------------------- ---------------------------------------- Address -------- ------------------------------------ Contractor's Name .......................... _................ .....................................License # ........................ Phone ---_----_------------------ Installation will serve: Residence QP Apartment House F1 Commercial oTraller Court 0 Motel Ej Other ............................................ Number of living units:.....1..... Number of bedrooms .3.......Garbage Grinder ............ Lot Size ................ ........................... Water Supply: Public System and name ........._................................................................._...............................Private, ' t: Sand E] Silt Cj Clay E] Peat E] Sandy Loam 0 Clay Loam Character of soil to a depth of 3 fee Hardpan,k Adobe C1 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 [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth .......................... Capacity .................... Type .................... Material............... No. Compartments ...................... Distance to nearest: Well -------- .............Foundation ...................... Prop. Line ...................... LEACHING L t INt No. of Cin-is.......................... Length of each line.,......----......_......... Total Length ............................ V Box ............ Type Filter Material ....................Depth Filter Material ............................................. Di I stance to nearest. Well ........................ Foundation -------_---------. Property Line ..................... SEEPAGE PIT Depth .................... Diameter ................ Number ............................ Rock Filled yes C] No 0 WoteiTable Depth ................................................Rock Size ................................ Distance to nejre' st, Well ...................... ................Foundation .................... Prop. Line ------------------_ REPAIR/ADDITION(Prev. Sanitation Permit# ............................ ............... Date .................................. Septic Tank (Specify Requirements) --- ................................ Disposal Field (Specify Requirements) _ Y .� 1•• �"" •��/ r ..�....7.._ "3 �'�'�?'!�/JM!',+�r ..........................................................................I............................................................................................. ............... ................................. ...................................................... .................................. ...... ............................ ...--•-----.---................ . ..... (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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner or licen. sed agents signature certifies the following: ploy any person in such manner "I certify that in the performance of the work for which this permit is issued, I shall not am as to b subject to W ,7eco.,su 11 9�1�an'�ompensatlonJaws of California." Sig W4.0r_,_/.............. Owner By ........................ ...................................................... ------ .... Title � ..................................................................... ...... . (If other than owner) 42 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ................................................................. DATE Z-.7-y. ................. BUILDINGPERMIT ISSUED ..... .......................... ........... ............................................................DATE ........................................... ADDITIONALCOMMENTS------------------ ............................ .............................................................................................................. ..................................... .................................................... ...................................................... ...................................................... ..................................................... ----•---•---------------•-------------------- ------------------...-......_......._...•--... ------------------............*......... --------------------1-1--------- ........I....... ............................... .. ......-1........ ......... ---------------------- ------------------------------------------------Date-Z . ........y Final Inspection by: --- --------- --- ................ ....................................... ...... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M