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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: .-.7- -----------------------------------------=---------------- ----------- -___.- ---- 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: 7►� JOB ADDRESS/LOCATION _ _ /-7, ------ -SI_I- ------- -- - � l- C� CENSUS TRACT �s - ---------------- 7 Owner's Name � - Phone - j R � L.n 4 c.� Address 7-5 7 �-• /l�-/.�_`�----------%- Ci /!/ - ��`/- ---------------------------------•--- Contractor's Name - .-f`'....- f9-.f' �! ---------------License # �� c %/ Phone Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ Motel E]Other Number of living units:-------/--- Number of bedrooms ___�C,cirbage Grinder ------------ Lot Size .-- 1 Water Supply: Public System and name -------------- - --------------Private Character of soil to a depth of 3 feet: Sand'C Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ 4 Hardpan ❑ Adobe [] Fill Material ---_--------If yes, type -.----____----------------- (Plot plan, showing size of lot, location of syste 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 availak le within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK+[ ] Size-------------------------------------------- --- Liquid Depth -------------------------- Capacity --'----- -- ------- Type -------------------- Material--------------------- o. Compartments ------•- ------------- W Distance to nearest: Well -----------------------------------Foundation ------- ------------- Prop. Line ---------------------- 'LEACHING LINE [ ] No. of Lines ____.----_--_---___ _ Length of each line---------------------------- Total Length ___------_---- ...-----_-J 'D' Box ------ Type Filte Material ---___-------------Depth Filter Ma erial -------------, _- ------ Distance to nearest: Well - - -------------------- Foundation ---_--___ _ --.----- ____ Property Line -----_-._- ---_- ------ SEEPAGE PIT [ ] Depth --....]------------ Diam ter ---------------- Number ------------ ---------- ---- Rock Filled Yes ❑ No i❑ Water Table Depth ----------- -------------------------------------Rock Size '-------- --- --------_ Distance to nearest: Well - - ------------------------------------Foundation --_L -- --------- Prop. Line ---------------------- --- , I- i REPAIR/ADDITION(Prev. Sanitation Permit# __________ ___ ----------------------------- Date ---------------- + i Septic Tank (Specify Requirements) --------------------- --------------------------------------------------------- DisposalField (Specify Requirements) ------------------------------------------------------------------------------------- ----------------------------------------------- e-P -------- ------------------------------------------------------------- ------------------ - ------------------- (Draw existing and required adI dition 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 Title ----- ----- --------- [If other than owner " FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------___1-__t ----------------------------------------------------------- ------ --. DATE -- --------------- ------- ------ BUILDING PERMIT ISSUED DATE --- ------------------------------- ADDITIONAL COMMENTS ---- ---- ------ ---- -------------------- ------------------ - ------------------------ - a - -- ------------------------------- ----------------------------------------- ------ - ---------------------- --------------- --------------- -- ---- -- - ---- ------ ----- - -- -- --- Final Inspection b - - - ----- --- Date -�_�_� - - SAN JOAQUIN LOCAL HEALTH DISTRICT i E. H. 9 1-'68 Rev. 5M