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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ------------------------------ - Permit No: --- 7 �-` - ------------ (Complete in Triplicate) I ----- --- -------------------------------------- p S _ C� Date Issued _,�-_�-�--_.. ' --_-----------------------"-_-------------------------_ This Permit Expires 1 Year From 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 ADDRESSAO ATION - ----- ----------------------------------------------------------CENSUS TRACT ----- ------------------ Owner's Name - -- !'�------- '7'�------------------------------------- = Phone " ... = Ci#Y / Address ----- ----- ---------------- Contractor's Name Q_a— U �aO W------------------------------------License # --------- -------------- Phone Installation will serve: Residence ❑Apartment House 10 Commercial-:RTrailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units:___________ Number of bedrooms ____________Garbage Grinder ---___ ---- Lot Size __________________________________________ Water Supply: Public System and name ---5_X1----------- ------vaqv -�-----------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑., Silt❑ Clay ❑ Peat❑ Sandy Loam ❑- Clay Loam-®' Hardpan ❑ Adobe ❑ Fill Material ------------ if yes,type ---------------------------- (Plot --------------------- "-(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 [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth --------------------,•---- Capacity - ------------------ Type -------------------- aterial---------------------- No. Compartments ---------------------- �] i Distance to nearest: Well -------------------- ---------------Foundation ________._____------- Prop, Line -------------_-,------ LEACHING LINE [ j No. of Lines _______________________ Length each line____________-___-----.-.---- Total Length ,__________-_______--------- 'D' Box .__________ Type Filter Materi --------------------Depth f=ilter Material _______________________.-.________-____-. Distance to nearest: Well _________ ___________ Foundation _----------------------- Property Line ______--__________---_-- SEEPAGE PIT [ } Depth Diameter ________________ Number --------------------- ------ 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) -------------=----- ----------------------------------------------------- ------------------------------ �� - Disposal Field (Specify Requirements) __��_..�i�� f -----��--�----- -�---�� -- "�=- --��-°i� ------------------------------- ---------- ------------- ------------------------------------------------------------------------------------------------------------------------- (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 �f G-------�`� ----------- Title - ---- -------------------- --------------------- -------- (If other an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Br-- ----------------------------- DATE ------ -- - r--�� - --------------- BUILDINGPERMIT ISSUED ----- -------------------------------DATE ------------------------------------------- ADD[TIONAL COMMENTS _ -------- - ---- ( c?df � d- C! C I - -. .------------- - v ---------------- ----------- ------------------------------- ---------------- 07 � DateFinal InspectionY- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'6$ Rev. 5M