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:Al FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. ` ---------------- ------------------ ----- ------ (Complete in Triplicate) ------------------------------------ Da.S 7 - Date Issued This Permit Expires 1 Year From Date Issue ------------------------------------------------------- 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/LOCATI N _ -. ' .-- ------- , CENSUS TRACT ` Owner's Name Phone ._-___-___ ---------------------•------------_ Address C 4 -_ ,_.. Ci#Y R --------; --e----- - Contractor's Name i- _ ------ ---------License # � Phone �, Installation will serve: �Residencartment House❑ Commercial :❑Trailer Court ;❑ k Motel ❑Other -------------------------------------------- 77 Number of living units:-------E---- Number of bedrooms --�..7------Garbage Grinder -- --------- Lot Size -------------------------------------------- Water Supply: Public System and name ------------------- ----- ------------------------------------------ Private Character of soil to a depth of 3 feet: Sand'[:] silt❑ Clay E-] Peat E] Sandy Loam E] Clay Loam I Hardpan ❑ Adobe ,F] 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 240 feet,) I PACKAGE TREATMENT ] ] SEPTIC TANK'[ ) Size------------------------------------- ---- ---- Liquid Depth ----.--_-----------,----- t - Type -------------------- Material---- ------ No. Compartments -----:---- •---=---- Capacity - ----------- - - YP Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------•------------ -_--- Total Length LEACHING LINE [ ] - No. of ,Lines -------------__---"-_-- Length of each line__-____________ - .- ----------------------------- 'D' - ----------------•--------'D' Box-.------------ Type Filter Material ------------------.Depth Filter Material -------------------------------------------- Distance ------------------------•------ •-----•---Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ----.-------------- SEEPAGE PIT [ ] Depth ��__________________ Diameter ------------- _- Number -------- ------------------- Rock Filled Yes ❑ No 0 Water;Table Depth -------- ---------------------------------------Rock Size ----------------------------•--- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -.-_-_-_-------..----- REPAIR/ADDITION(Prev. Sanitation Permit:# --------------------------------------------- Date ---------------------•------------) I Septic Tank (Specify Requirements) -------- ---------- ---------------------------------------------------------------------------------•----------,.---------------_--------•-- Disposal Field (Specify Requirements) ----------- -------------------------------------------------------------•--------------- r ------------------------------ ------------------------------------------------------ ----- - _ --- ------------ ----- ---------- r,� r � 1 ---- 3-----------------------I --------- (Draw xistin end re red 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 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 Workr"an's Compensation laws of California." Signed -------------------------------------- ------------ --------------- r = --- Owner-.-- --- --------- - �. (If other than owner) j FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - i ---------------------------------------------- ----------------- DATE _/-U--------- --�-�---•--------- %BUILDING PERMIT ISSUED ---------------------------------- ---------------- DATE -: ADDITIONAL COMMENTS ------------------------- ------- - ----------------------------------- --------------------------------------------- -------------------------------------------------- -- -----------------------------------------= I r ---------------- ----------------------- ---------- ----------------------- --- --- ---------------------------------------Final Inspection by: ------------------------------------------------------------------ Date 7 ----- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M,