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r FOI OFFICE USE: APPLICATION FOR SANITATION PERMIT .................I.............I......................... (Complete in Triplicate) Permit No. _..7 �✓1 --••• 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 ..............................CENSUS TRACT' Owner's Name ._....... .._ �7 - � e ••-----••--•...............•-.............-- Address •. �...l o_n - r. ,1?2 ----_---- City -r Contractor's Name .... ,c•$,# .-- .... -_.License # ``. �'j... Phone Installation will serve: Residence Apartment House 0 Commercial❑Trailer Court 0 Motel ❑Other ............................• Number of living units:.._../ .. Number of bedrooms .._ ..Garbage Grinder " Lot Size ... Z • f ----,� 4 Water Supply: Public System and name .__. _ -._ c�1� 4 ..•••___--•-•• ----- Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay [] Peat❑ Sandy Loam fl Clay Loam Hardpan ❑ Adobe-0� 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 700 feet,J PACKAGE TREATMENT [ ] SEPTIC TANKLW 5ize... ,�! :_ /4- ---------•_... Liquid Depth A.—.-•----•-•------� Capacity/. �swG �TYpeMaterial._. 4 No. Compartments .... - f Distance to nearest: Well .A,_h.- .dka. _•___--_,Foundationf � ..Z�-----....... Prop. Line .....4 ............ 1EACHWG LINE ` No. of Lines .........f.._••--_-- Length of each line..........._._..... Total length . P'6.;r-.-:...... 'D' Box . . Type Filter Material _/ ___Depth Filter Material ' - _••... Distance to nearest: Well . `�e- �Foundation .A7_1.......... Property Line .%5.�-._----.•...._ SEEPAGE PIT Depth `�� ` p ....------ Diameter eX02...--- Number Z................ Rock Filled Yea JX No 0 Water Table Depth x9a...............................Rock Size ----- -----------------••--- Distance to nearest: Well _. .frc� �:-•,..--Foundation ... Prop. Line -. tS— r REPAIR/ADDITION(Prey. Sanitation Permit!# ................ Date ........._. ) Septic Tank (Specify Requirements) r 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 employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ----- .. Owner - �-- --- ........ ...... BY .c :c__ •-- ------- -- ----�.-•-•--•-------- Title ...._. � . _ ..... ! ..._.�................... (if other than owner) R DEPAR ENT USE ONLY APPLICATION ACCEPTED BY2b-7 -----------•-- ----- -•----••-•.....................••--•-..... DATE .:.............. BUILDING PERMIT ISSUED .•---• :.............. ....... ADDITIONAL COMMENTS . .............. ............. ...............................•-•--. .. ... . .... ...................................--•---..... _.........._..•---- •. -----....--- Final Inspection by: ....: ' ---- --- . . ..... ........ •-------•------....---....................................Date _ ...�_'.�.1.� ....._.. SAN JOAN LOCAL HEALTH DISTRICT E. H. 13 24 W68 Rev. 5M 717