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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------- - ¢' (Complete in Triplicate) Permit No. 72_____ ----------- This Permit Expires 1 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 comp!ianc with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION / - ------------------------------------------CENSUS TRACT Owner's Name t �I - ------- - - -- ---- --------------- Phone ._ `7 `�w1 ...----- Address ------------------'- -------- - - --------- City ---------------------------------------------------------------------------- Contractor's Name .. '- License #(_ �� Phone {�_�-f6o.7 Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other -------------------------------------------- Number of living units:_____ Number of bedrooms _-_Z<Garbage Grinder ---- ----- Lot Size -- - __I�Z�J_______ Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ `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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) \� PACKAGE TREATMENT [ I SEPTIC TANK'[ I Size------------------------------------------------ Liquid Depth ------------ ---__------ Capacity --------------------- Type -------------------- Material--------I-------------- No. Compartments --------- Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line -__-_________________- LEACHING LINE [ ] No. of Lines ------------------------ Length of`each line----------------------------- Total Length _---__-____-___________-____ 'D' Box Type Filter Material ____________________Depth Filter Material ----------------------------=:________-___... Distance to nearest: Well ________________________ Foundation ------------------------- Property Line ________________ SEEPAGE PIT ( J Depth ________________ Diameter ________________ Number .--------------------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ___.___-___________________________Foundation -------------------- Prop. Line .........._.__.___..__ REPAIR/ADDITION(Prev. Sanitation Permit --------------- ----- ---- ----- Date --------.------ .._.__�.-.....-�} Septic Tank (Specify Requirements) _____ ______ ___ __ ______ _ -_�l ___F! _C __ zj�t� _____.____... Disposal Field (Specify Requirements) _____________ ------------------------------------------------ ----------- -------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- (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 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 einploy any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---- ------ ------ Catno - --- - ----------------------------------------------------- Owner � BY ------------------------------- Title ----- --------1--- - ---------------------------------------------------- ---- ---------- (I her wner) FORDEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ ________- DATE ----- ! o _._. _^ -____- --- ---- -- ---------- -------- -------------- ----------------------- BUILDING PERMIT ISSUED ---------------------------- ----DATE ----- ------- - ------------ ADDITIONALCOMMENTS --------------------------------------------------------------------------- ---------------------------------------------------- --------------------------- ------------------------------------------------------ _ _ ---------------- --inal - - t - y Tr -- ---------- ------- Date d. Final Inspection by: -- -__-•-- - ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M