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FOR OFFICE USE: APPLICATION FOR'SANITATION PERMIT 7S-/ 3 -------------- ------------ ----------------------- ;Complete in Triplicate) Permit No_ ----------------- 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/LOCA `�3 ___�-', -�L '` -�NSUS TRACT _� r i Owner's Name -J - -- - ------------------------ Phone city /-KY-/ wl Address --------1_v �� -------------------- rX!! 7. Contractor's Name . --- �---..---- ---- # - -- - ---- Phone 4___----------------f/____- Installation will serve: Residence Apartment House�❑ Commercial ❑Trailer Court ;❑ > Motel ❑ Other ---- ------------- ------------------------- Number of living units:----!------ Number of bedrooms _3-----Garbage Grinder ------------ Lot Size r _________________ Water Supply: Public System and name ----------------------------------•---------------------------------------------------------------------------.Private Character of soil to a depth of 3 feet: Sand'' Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ y ry Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ____________________________ W (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 [ I SEPTIC TANK:[ ] Size_______________________________ ________________ Liquid Depth -------._._._____________- m Capacity -------------------- Type -------------------- Material------ No. Compartments ------ --------------- Distance to nearest: Well ______________________ _________Fo dation _-.__ Prop. Line ________________--.__. LEACHING LINE [ J No. of Lines ----------------------- Length of a ch line-- --------------------- -- Total Length -----------.----------___--- j D' Box ------------ Type Filter Material ---- ------------- epth Filter Material -------------------------------------------- - ___-________________________________.---_-- P Distance to nearest: Well ____________________ ___ Foun tion ----__.-__.___-___.__.__ Property Line ___-___-____-__-__._.___ SEEPAGE PIT [ ] Depth -------------------- Diameter -_-_--- __.-- Nu ib - _.__._____._______.___.____ Rock Filled Yes ❑ No �[] Water Table Depth ---------------------- --------------- -- ------Rock Size ------------------------------- Distance to nearest: Well __________ _____________ ___________Foundation ___________._______ Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _______________ ___________________________ Date ________-_-___._-_-____-__-_______) Septic Tank (Specify Requirements) -------- -------- ----------------------------------- _ - _J---'-'-_____ f ___ --_-----_Disposal Field (S ecify Requirements) eyl __________/ s . . 5 _ - --------------------------------- ----- (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 Work n's Compe�sati.o laws of California." SignedAll ---- Owner ' By - ---------- --- ----- - ------------------------------------ Title ---- ---- ------ --- -- ----------- ---------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------------------------------------------------------------. DATE ----- ------------------- BUILDINGPERMIT ISSUED ----- ---------------------------------------------------- - ----------------------------- -------DATE -------------•----•------------------------ ADDITIONALCOMMENTS ------------------------- -------------------------------------------- -------------------------------=--------------------------- --------------- ----------------------------------------------- --------------------------------------------------- ------------------------------------------------------------------•- -- ----------------. ------- - ---------------------------------------------------- ---------------------------------------- -- Final Inspection by: Date --- S--dY-X21.6------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M