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FOR OFFICE USE: it M t APPLICATION FOR SANITATION PERMIT - - - Permit No: .�_Z_7 / - (Complete in Triplicate) ---- ------------------------------------ _ ---------------------- This Permit Expires i Year From Date Issued 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 compliance with County Ordinance No. 549 and existing. Rules and,Regulations: JOB ADDRESS/LOCATION . i / CENSUS TRACT �J -7-kP�g� P Owner's Name _ >!.�� ---_.��_�Y. -�124�-- -- ----Phone A ' -- - -- --�- � --_--_-� fA_ fAddress Y = -l Cit --- PhoneContractor's Name ----/ .L_Z`L_Z_i;WZ--- _ ,3�•?' License # - t Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ',❑ 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'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ z Hardpan ❑ Adobe (Fill Material ---__------ If yes,type ---------------------------- (Plot _________________________(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,] pv� i 6 PACKAGE TREATMENT ( I SEPTIC TANK [ jSize _______-_ Liquid Depth ---h Ca' acit p Y --�� ---,TYPe --��t_ l�Material- ---- No. Compartments ,------------ H Distance to nearest: Well --------7!0---------------------Foundation ----ee ------------ Prop. Line --- ___________ LEACHING-LINE [ ] No. of Lines ----- _ Length of each line__.___fa-__ ___._____ Total Length - ...__...__ 'D' Box ---�-__.- Type Filter Material Depth Filter Material ------ Distance to nearest: Well ___ _____________ Foundation ----- --- ------------------ Property Line __l. ___- SEEPAGE PIT [ ] Depth ___________________ Diameter -------- ------- Number ---------------------------- Rock Filled Yes '❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ----------------------••---•- Distance to nearest: Well ________________________________________Foundation --------------------- Prop. Line ____-_________________ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ------------------------ --------------------------- DisposalField (Specify Requirements) ------------------------------------------ -------------------------------------------------------------------------- ------ ---- t --------------------------------------------------- -------------------------------------------------------------------------------- ------------- -------------------------- -----------•------------ R -------------------------------------------------z _ (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 licew sed agents signature certifies the following: "1 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 , s__�if� ---- -------- Owner ' BY ------ - ----------------------------- ----------- ------------------- Title -------- --------- (If other than owner) FOR DEPARTMENT IJSE ON4Y APPLICATION ACCEPTED BY ----------------------------- ------ - 2 --- -- Y=_. DATE - BUILDING PERMIT ISSUED --- ----- DATE ADDITIONAL COMMENTS ----------------------------------- ------ -------------------------'------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------ - ---------- ---- - Final Inspection b --- ----- -- - - -- - - ----- P Y - - -- --------- -Date -- SAN JOAQUIN LOCAL HEAL DISTRICT ,4 E. H. 9 1-'68 Rev. 5M.