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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -7/_ w Permit No. --------- I ------- ---------- -------- ----- --- ---- (Complete in Triplicate) � - -------------- Date 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 insfall the work herein, 2 described. This applicati�/ �de,i c liionc with County Ordinance No. 549 and existing Rules and Regulations: pC'�J ffPhone JOB ADDRESS/LOCATION ___- _I D - _-- a--------lN----_----_f�- -M/T1el2S_CENSUS TRACT --------------•---- 0000 Owner's Name _. _ -2 2Y�_t/ ------------------------------- Address ---9- aI -,-S4------ 19M _ ,e -s-----1�--------------- City ,C ------------------------------------------- Contractor's Name ._.-� Li�ense # - .j --- Installation will serve: Residence ❑ Apartment House Commercial Trailer Court ;❑ 1 ti Motel ❑ Other -------------------------------------------- Number of living units:-----t*4_-_ Number of bedrooms --.J____.Garbage Grinder ------------ Lot Size --------------------------------------- Private [$ Water Supply: Public System and name ---------------------------- ------------------------------------------------ --------- € Character of soil to a depth of 3 feet: Sand'❑ Silt C-1 Clay E] Peat❑ Sandy Loam [] Clay Loam Eli mr - _ 4 s -� 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.) + :i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) L -----=-------- Liquid Depth --- 7- TANK Size___ _ --�-- q P PACKAGE TREATMENT [ ] [ ] �- - 1�.� p --r- n----- Capacity Typeek - Material-- '� ' No. Compartments ..� k Distance to nearest: Well __--6D 1-------- --------- - Foundation �.------ Prop. Line Length of each line.- 'D' !��-------------- Total Lengt�� o" LEACHING LINE [ ] No. of Lines _.-_ nn-- 'D' Box ------------ Type Filter Material !44k-----Depth Filter Material ----- -_------ f t .--- Foundation a ---- - t Property Line --- ------------------ Distance to nearest: Well "-.___ -------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------------- ------ Rock Filled Yes ❑ No Water Table Depth Rock Size -------------------------------- Distance __________________-__ _Distance to nearest: Well -------------------------------•----- ---Foundation -------------------- Prop. Line ---- ----------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- Date ----------------------------------} Septic Tank (Specify Requirements) ------------------------------------------------- ------ ---------------------------------------------------- Disposal Field (Specify Requirements) ----------- --- ---------------------------------------------------------------------------------------- I ------- ---------------------------------------------------------- ------------------------------------------------------ ----------------------- ------------------------------------------------------ (Draw existing and required addition on reverse sie I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Siate 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 Workman's Compensation laws of California." Signed ------- -- -- --- fi - Owner ------------------------- ---------- -------- Title --------- --------- ----------------------------------- --- - ---------- (If other fihan owner) FOR DEPA1tTM T SE NLY APPLICATiON ACCEPTED BY ----------------------------- --------- ------- DATE 7 ----•------------------- -------DATE --------- --------- -------- ---------- BUILDING PERMIT ISSUED ----------------------------------------- -------------- - ----- - ------- --------- �.� ADDITIONAL COMMENTS ---------------------------------------------------------------------------------------------------------- ------------ ------------------------- ----------------------------------------------------------- .r ---------- -------- -------- --- -------------------------- ---------- -------- ------ ------ �" _ --- -----Date - - _'/� � -------- -------- Final Inspection b " " ! SAN JOAQUINLOCAL HEAL H (STRICT' E. H. 9 1-'68 Rev. 5M