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t FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. 7 -7� - p ----------------- -------------------------------- {Complete in Triplicate] - -- ...... _--------------- This Permit Expires T 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: 1 , JOB ADDRESS/LOCATION .--------- 1_ pcU�y/ os�------------C'G,�_ :----CENSUS TRACT Owner's Name ------------- tp ------2,51,^d!+yn/--------------------------------------------------------------------Phone---------- Address --. .y----------------------------------•--. City ------'rv-'a- - - -ConContractor's tractor's Name --------S� --------------------------------------------- ---------------License # --------- -------------- Phone -------------------- 1 Installation will serve: Residence ❑Apartment-Hou se-'❑.Commercial [Trailer Court sg > Motel ❑Other - [ Number of living units:-____I_____ Number of bedrooms ----A----Garbage Grinder ------------ Lot Size .____ --------- o-e I Water Supply. Public System and name ------------------ -----------------------------:-------------------------------------------------------------Private � 4 Character of soil to a depth of 3 feet: Sand' Sift-0 Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam.n Hardpan ❑ Adobe '❑ Fill Material J--- ______ If yes,type ----------______________ It (Plot plan, showing size of lot, location of system in relation to w_ells, 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:[t}/ Size___________y________-- � / Liquid Depth Capacity ------- Type Mater idl`<541-_r_tg No. Compartments .___4-r tj D' tante to nearest: Well _ 1 -----------------`-- --�Foundati`n --'��----------_w_ Prop. Line ��-�--------� LEACHING LINE [ No. of Lines _-�-_.________- --- Length of each--line---,7C>__------------ Total Length ,__%�i� --_. D' Box _-__:-Type_Filter.Material --------- ----------- V% Filter Material _________,�1�� - N -------- Distance to nearest: Well ___� __�_________ Foundation __-r'5_ ________Property Line v -_ -__. _ --- SEEPAGE PIT [ ] Depth ------------------- i Diameter ----------------- Number ---------------------------- Rock Filled Yes ❑ No .i❑ Water Table Depth i----=-- -----=---------------------------Rock Size _F__,~ Distance to nearest: Well _:__ €_______________1"�- ITJ-_:____. _ - Foundation's__.!- .-_-_-.-_-_- _-_-_-_-_-_-_-_-_--)Prop. Line _.___________. ..__-_ REPAIR/ADDITION(Prev. Sanitation Permit# -------- -___ --------- ---------+--------- Date ---------------- Septic ---------•-----Se tic Tank (Specify Requirements) = -- { -------------- -------------------------- --------------------------- Disposal Field (Specify Requirements) ______________ ________ ------------ --------------------------------------------------- -------------------------------------------- i 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,Son 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 suub�ec to Workman's C mpesatiuon laws of California." Signed /� .t.✓Y ------------ Owner By -------------------------------------------------- ----------------------------------------------------- --------- ---- ------------- -------- ---- ---- Title -- ------------------ (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __-- - DATE -----------` ------ - •------ BUILDING PERMIT ISSUED -------------------- -- --------------- DATA ---- ------------------ TlONAL COMMENTS _____________----------------------------------------------------- --------------------- ------------------------------------------ R ---------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------ I } ----------------- Finalf Inspection by: t { ------•-------- ------------- ----------------------- SAN �(- - ---------- ----- - -------Date - - ----`---------- - SAN JOAQUIN LOCAL HEALTH DISTRICT H. 9 1-'68 Rev. 5M.i' -�-