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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. -------- ------------------------- __________-_ This Permit Expires 1 Year From Date Issued Date Issued __:77712-73 Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with Co my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOC ATI -�v -- -------- -- CENSUS TRACT 7 Owner's Name -------- -- ------- // -•---------------�--- --�---- --� Phone -------------- --------------------- Address ----------------L- L-0 - --------- ----------- --- --------- Cty.+� _ --------- ----------------------------------------------- Contra - -----------------------------------•--•-------- Contractor's Name -----Z: ; - ----,a---- ---`--------`----- ------------------ -- --------License #1 3 -Y Phone Installation will serve: Residence � Apartment House❑ Commercial -❑Trailer Court I❑ Motel ❑ Other Number of living units:----- -- Number of bedrooms __0-------Garbage Grinder ------------ Lot Size ______ _ - ------- ------------ Water Supply: Public System and name ------------------------------------ ______________________ _ -----___Private Character of soil to a depth of 3 feet: Sand' Silt[-] Clay El Peat E] Sandy Loam E] Clay Loam Hardpan ❑ Adobe ❑ Fill Material ------------ if yes, type ---------------___-_-_-__ (Piot 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 -------1------------ W LEACHING LINE { ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------.---------------- 'D' .'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------ -------------.----------. Distance to nearest: Well _______________________ Foundation ----------- ------------ Property Line ------_-_-_...__..._.__ SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------- Rock Filled Yes ❑ No ❑�Y Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ------------------------•---------------Foundation -------------------- Prop. Line -------------•-----_-- i REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) (10 Septic Tank (Specify Requirements) ------------- --------------------------------------------------------------------=------------------------ •.<- Disposal Field (Specify Re ui ments)i ---- ___________________ ------- ----------- ------------- , - - --------------------------3---- ------- --- - - ----------- a� ---- ------ --- ----- ---- -------- ------------ -------- -------- ---------- ---------------- ---. ----- ---- --------- ------- t / - � (Draw existing and required addition on revers ide) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 3 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 orkman's Compensation laws of California." Signed -------------- - - --- ------ - --- --- --- - - ------ -Owner I By ---------- ----------- ------ Title ---- ------------------ - (If of er than owner) I FOR DEPARTMENT USE ONLY �7 APPLICATION ACCEPTED BY - - -- ----------------------------------------------------------------- DATE -!_ �._ BUILDING PERMIT ISSUED ------- ----------------- ------------------- -----------------------------------DATE ---- -------- ADDITIONAL COMMENTS ---------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ --- ------------------------------------------------------------------------------------------------ ------------------- ------------------------- _ -- ----- -------------------- - Final Inspection by- -------- ---------------------------Date. -f SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M