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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------- ----- -------------------- I (Complete in Triplicate) Permit No: -7 Z____�_•`f_3 ---------- ---------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued -_1-13 __7v Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work hereinr,+ described. This application is made in compliance with Cou ty Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO - _.-CENSUS TRACT _-_------------------- --------- - Owner's Name .-- p 77 -------Phone Address e City ---------- ----------------------------•-•----- f �3�z Contractor's Name --- -- --------- ----- - - ---- - ---- -------.License # -/-� . ------------- Phone ----------------------------•- Installation will serve: Residence Apartment House°0 Commercial ❑Trailer Court ;❑ 4 Motel ❑Other ----------- - Number of living units:----- Number of bedrooms --�_-__Garbage Grinder ------------ Lot Size ------ ' Water Supply: Public System and name --------------- --------------------Private Character of soil to a depth of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam Clay Loam Hardpan ❑ Adobe E] 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 ublic sewer is available within 200 feet,! r ` PACKAGE TREATMENT SEPTIC TANK' G Size- ------ ------------- Liquid Depth ---5--------------------- Capacity Type ___ Material-_----___�-lhL Cir y-_ No. Compartments -�._______. ----- Distance to nea Well --- ---- A - ----_-----------�---_-._•---------Foundatio n -----f V-I--------- Prop. Line _-� f_- --_---- LEACHING LINE ] No, of Lines _------- ------------_- Length of each line_-- _ _�n d !�► . I--_--_ Type Filter Material ------- % Depth ,Filter Material ---�1-----_______•_ ! Distance to nearest: Well ------- ------- Foundation ------------ Property Line ---;�7. .............. SEEPAGE -- SEEPAGE PIT [ ] Depth - ----------- ------ Diameter --------- ,-_:- Number-----_- --_--------.---- Rock Filled Yes [] No Water Table Depth -------------------------------:- `-- - ------..Rock Size ---------------=J -= ------ Distance to nearest: Wel! ----------------------------------- ,__`_•Foundation -----------_-------- Prop. Line _--------------:_-••- -- REPAIR./ADDITION(Prev. Sanitation-Permit# --------------------------------- _--_-_-- -- __ -----' Date _ i ------•---------- y Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) -__---_-_-_-_ i -------------------------------- ---- ------------------------------------------------------------- - ------------------------------------------------------ -- . , ------- -------------- ------- ------------------------------------------------------------ ----------------=---------------------- #(Draw existing and required addiflon-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. Nome 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 - ---------- e BY - -- - ------- --- =-- ------ Titi - = . e _ °` —�= —---------------- (If other than owner) ' FOR DEPARTMENT USE ONLY' - APPLICATION NLY' -APPLICATION ACCEPTED BY --- --------------` - , -- ------------ - ---------- ---'- - DATE ------ BUILDING --',l-�"`-- PERMIT ISSUED ---------------------------- -- = - ------------- ----------- � - - ----�- - ----------DATE -------------- ADDITIONAL COMMENTS - ------------`--- ------------ --- -- ------------- -------------------------------------------- ------ - -------- - ------ - - ---- - - - ------- - �= - Final Inspection by. ► -- - -----.Date ---- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M