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. FOR.�OFFIC USE:µ APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: ` __-_-______________________ This Permit Expires 1 Year From Date Issued Date Issued0= 7=_ )/ R I � 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/LOION . 7 ----------------------------------------- ------------------------ CENSUS TRACT - Owner's Name -- ?¢ ------------ =------------- ---------------------------------=- -------Phone _`_as�_s _. Address _ _ fG ------- City .1��` � jf Contractor's Name �_—r l/�E'---------------------------------------- - A/ - Phone �} � License -_�� Installation will serve: Residence [j?Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of living units:-----f__.. Number of bedrooms _ ":__Garbage Grinder -----------.- Lot Size -______---..___ ~ Water Supply: Public System and name ---------------------------------•----------------------------------------------------- ---------------------.-Private Character of soil to a depth of 3 feet: Sand 5�^ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 IHardpan ❑ 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 [ ] SEPTIC TANK'[ ] Size.-- ------------------------ ------ ------------ Liquid Depth :------------------------- V\ Capacity ----------------- Type ----------------- Material-..,_`-__- - No. Compartments ................. Distance to nearest: Well ________________ ______Foun tion _______.____._______ Prop. Line __--_________:_.______ f LEACHING LINE [ ] No. of Lines ------------------------ Lengt of each line---.- --------------.-_---- Total Length -----_......----------____-- .. 'D' Box -- _.- Type Filter Mate al -------------------- pth Filter Material --------------------------- .......... Distance to nearest: Well ________ _________--__ Founda ion ----------- ---------- Property Line_ -__-________-:___-__-___ } SEEPAGE PIT [ ] Depth -_.__._______--__-- Diamet _______________ Num er ---------------------------- Rock Filled Yes ❑ No .0 Water Table Depth ---------- ----------------------------- -----Rock Size -------------------------------- •+ Distance to nearest: Well _____________________________ ________Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION ________-__-:___-.__REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------.----------------------1 SepticTank (Specify Requirements) - - ------------------ ---------------------------------------------=---------------------------------------------------------------------_- k Disposal Field (Specify Requirements) -----------------------------•----------------------------- -- -- p,_.. -------- -------- - - -- -- / Jr -------------- ------------- --------------- = ----------------------------------------------------------------------------------------------------------------- t(Draw existing and required addition on reverse side) ';. I hereby certify that I have prepared,this application and that the work will be done iry accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hedith 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 Wor man's.Compensation laws of California." Signed ---------- - ---------------a----- ----------------------------------- Owrier BY ....... ------ --- ---- ----- -------- ---- ----------- --------------------- Title .--- - ----------------------------------------- (If other than owner FOR DEPARTMENT USE ONLY : APPLICATION ACCEPTED BY --- = DATE L BUILDING PERMIT ISSUED ----- - DATE ADDITIONAL COMMENTS --------------------------- 1 - --------- -- --------------------- -------' --- ------------------------------------------------------------------------------------------------ ---------------------------------------- --------------------------- -------------------- ----------------------------------- - -- - ---- ------- --- - I ------------------------------- ,------------------------ -- ,� final Inspection b 1 P Y- 4'"�.- ;: -----------'------ Date __ ._. _ _ SAN JOA UIN LOCAL HEALTH DISTRICT ` = 9 1-'68 Rev. 5M.