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FOR OFFICE USE: APPLICATION FSR SANITATION PERMIT ------•-------------------- (Complete in Triplicate) Permit No. __7/--------------- --- 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .--17 3_ S' CENSUS TRACT ___SVC ... I........... Owner's Name ------- i 0_%rnt�----------------------------------------------------------- --_--------•-----------Phone �_�...' I- t- 73-.--- Address __Y7_._.s'.s".--- f- ------ ------------------- Ci Contractor's Name ------ - -,� _r --------------- --------------------------------- = ........ License #......................... Phone .............................. Installation will serve: Residence q Apartment House❑ Commercial ❑Trailer Court Q 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 0 Silt ❑ Clay ❑ Peat 0 Sandy Loam 0 Clay Loam ❑. Hardpan ❑ Adobe ❑ Fill Material ........... If yes, type _____•______________________ (Plot plan, showing size of lot, location of system in rel do o wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit p d if public sewer is available within 200 feet,) _ PACKAGE TREATMENT [ ] SEPTIC TANK f ] ize ------------------------------ _----------------- Liquid .Depth .... .____._..---.___,,_..__ � Capacity -------------------- Type --••........... Material_.--- ---------- No. Compartments ................. Distance to nearest: Well ___ ________________-__-_-___---.Foundation ..__.___--__-___-___._ Prop. Line .__.................. LEACHING LINE [ ] No. of Lines ---- .._.____--___.__ ength of each line____________________________ Total Length _.____.-___-____.___.---.--- 'D' Box ------------ Type Fit Material ____________________Depth Filter Material ....................................... Distance to n est: ________________________ Foundation ____________..__._.____- Property Line ........................ SEEPAGE PIT [ ] Depth __________ __ ____ ameter ................ Number --------------- ------------ Rock Filled Yes ❑ No .0 WaterTable epth----------------------------------------------- Rock Size ---------•----------------•----- Distance to ne rest: ell________________________________________Foundation ___________---- Prop. Line ._................... REPAIR/ADDITION (Prev. Sanitation Per it ____________________________________________ Date ----------------------------------) SepticTank (Specify Requirements) --------------------•------•-•--------------------------•-----------------------------------: ----------------_•-- -............ Disposal Field (Specify Requirements) __._.._470�__t.� _-------_._�__-___r. %Z�-�ss�___/',�i 1----_ /p'�-',_r'_ _ ---------------------- -------- ---------------- - --------------------------------- (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 employ any person in such manner as to be70___rx� subject to Vor. an's Compensation laws of California." Signed �i. -wG,------------ ------------------------ Owner BY-------------- --- -- Title ---------- -------- --•---------•------------------------•----•------ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_._!/-��ls+L-------------••-•---•--•------------------------ •---------- DATE _'_��:7/ ...------------------ BUILDINGPERMIT ISSUED----------------------•----••-•--------•---•-••----•-----•-----......................................... DATE ----------- -------_----_---------------- ADDITIONAL COMMENTS -•-----------------•-•--------•------- - --------------------•--------------------------------••-----•----------------------------------------------------- ------------------------------------------ ---------------------------- ------------------------ "'�- -------•---•-•----•--------•-••-----•----------•-------•---------------_•-----•----•-----------------•- -------------------------------- ------ -- ` Fina Inspection by •-•-------- Date -------- _-•------•---•---------- •------- SAN JOAQUINs LOCAL HEALTH DISTRICT /JIJ E. H. 9 1-'68 Rev. 5M `�