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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ----- --------- ----------------------------------- Permit No. -7_V-_�.P' --------- - (Complete in Triplicate) ' --------------- ----------------------------------------- Application -----------------_-_--_--_----- This Permit Expires ] Year From Date Issued Date Issued A lication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein PP Y a described. This application is made in compliance with County Ordinance No. 549-and existing Rules and Regulations: JOB ADDRESS/LOCATION 9�� R.-S_ 5¢.---------------------------------------------------------CCENSUS-TRACT' '..,___ Owner's Name I7� x t© � 3 � ----------------- -------------- Phone � ll-�J�1� Address ---------------- --------------------------------------------- ------------ City ------ 4 C° ✓ l ------------------------------------ Contractor's Name r ---- _ { �� xYt .license # -` fes Phone Installation will serve: Residence Qd Apartment House f-] Commercial ❑Trailer Court i❑ Motel ❑ Other -- ----------------------------------------- Number ---------------------------------------Number of living units:--/------- Number of bedrooms ____Garbage Grinder ------------ Lot Size --- ---------------- _d-- --. Water Supply: Public System and name ---------------------------------------- -----------------------------------------------------------•---------Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam.❑ t Hardpan ❑ Adobe 0 -Fill Material ------------ If yes,type ___________________________ ' (Plot plan, showing size a lot,location of system in relation to wells, buildings, etc. must be placed on reverse .side.) ' f i NEW INSTALLATION: (No.se,:..ptic tank or seepage pit permitted'if public sewer is avallbble within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK'[ ] Size------------------------------- q4 p Capacity ---- --------------- Type --•----------------- Material------------- "'* No. Compartments -----------••----_---- Distance to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line -------------.•------- l LEACkNGLINE (J No. of Lines ----.----/--------.... Length of each line---- y__r�___�____ Total Length __ 4__--__________--0 I I 'D' Box .--_1----- Type Filter Material -----a--'_r----Depth Filter Material ----------1__9_-f--..-- ------------- Distance to nearest: Well ______ _-___f- Foundation --------_ Property Line ___ -d-_�____ © ; SEEPAGE PIT Depth .... _`�__ _ --_ Number _______ ______________ __ Rock filled Yes ® No i❑ __ Diameter ______ ' Water Table Depth Rock Size _______ __________________ p --------- -- y► Distance to-nearest: Well -----------------------Foundation ____ Prop. Line __ .._____,'__. REPAIR/ADDITION(Prev. Sanitation Permit # --------------------------------- Date ---------------------------------- 10 ' Septic Tank (Specify Requirements) ---------------''= ,- ----------------------------`-------- --------- -----;------------- - ------------------------ Disposal ---------------------_Disposal Field (Specify Requirements) --__----_' �__"F____ --� ----{� "-- = ------- ---------------------------------------------------------------------------------------------------------------------------------- ,-' (Draw existing and required addition on reverse side) .' I hereby certify that I have prepared this application and that the ork 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 liven- sed agents signature certifies the following: N 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 L --------------- Title --- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY & 4' f DATE ----------7� BUILDING PERMIT ISSUED.------------------------------------- ------ = DATE ' ADDITIONAL COMMENTS ------' a ------------------- '--------• ---------------- --------------------------------------------- ---------------------------------------------------- ---------------------------------------------------------- --- ---------- --------------------------------------------- ---------------------------------------------- ----ems- _ ---•------ Final inspection by: _. _. -- - -------- -----^Dat - SAN JOAQUIN LO L HEALTH DISTRICT J E. H. 9 1-'68 Rev. 5M