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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT 7�/`7 ;Complete in Triplicate) Permit No_ _____________________ ----------------------!'_ This Permit Expires ] 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 .__ C''l '-/�----- ' /-N----- -�l��tr ------ - - - ----- - - --- ---- ---------CENSUS TRACT ----- Owner's Name --------- , / --------------------------------------} - -------------Phone ' -- --- ---1----1--• Address 1 raj ,-� T - �'= 7 -- ---- --------------- Cit /__1 �3__ / --�ty---------------------------------------- ---- Contractor's Name _.. Y /��'� ----�i��Lf�--f/_-`'P---------------------------=---- ---License #�f��J�f:�--- Phone Installation will serve: Residence ❑Apartment House-[g Commercial ❑Trailer Court ',❑ Motel ❑ Other ------------------------------- Number of living units:__________ Number of bedrooms -------------Garbage Grinder ------------- Lot Size _______________________________________ Water Supply: Public System;I. rd name ---------------------------------- ---------------------------------------------------------------------------Private ❑. Character of soil to a depth of 3 feet: Sand'j Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam'❑ Hardpan ❑ Adobe ❑• Fill Material ------------ If yes,-type--------------- (Plot ____--(Plot plan, showing size of IM t, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT { ] SEPT QTANK; Size - Li . � quid Depth ��r Ca I�city Type• Material_�r ►2 c No. Compartments __�— /V 1 ista1nce to nearest: Well Lente-f-----------------F,oundation ---�_--_--�__,____ Prop. Line __d�/________- LEACHING LINE [ No. ��f Lines -�____ :_ `__ g each line_i._ �� 6 � 7r ---------- ---- - Total Length ._��-------------- D' Box ___/_____ Type Filter Material _ _Depth' Filter Material __� �_____________________.--------- Distance _.______Distahce to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------•-.-•- i SEEPAGE PIT [ ] Depth ---_-----_----______ Diameter ______________ Number ---------------------------- Rock Filled Yes ❑ No 0 Watelr Table Depth ------------------------------------------------Rock Size -----------------------•-- I Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------_-----, REPAIR/ADDITION(Prev. Sanitation Permit# --------___--------------------------------- Date ---------------------------------- I SepticTank (Specify Requirements) ---- --- - ----------------------------------------------------------------------------------------------------<-----------------------•---- DisposalField (Specify Requirements) ---------- ------------------------------------------------------------------------------- ------------------------------------------ --------------------------------------------- ----------------------------------------------------------------------------------- ---------------------------------------- -------------------•----- { ------------------------------- ------•--------�� ----------------------`--------------------------------------------------- --------------------------------------------------------------------------- T, (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 shalt not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed Owner -- -. - - l� ----------------------------------- B YOwner ------ Title ---------------- (If o er than ow`n r) II FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1M._ -------------------------------------------- DATE --,-.- - �-7 ............ BUILDING PERMIT ISSUED ---��-------------------------------------------------------------------- ---- _--------------DATE --------------- ----- ADDITIONAL COMMENTS -----,I=--------------------_- _--- -- V ---------------------------------------------=------------------------•-- ------------------------------------ -------1M--- - --------------------------------- --------------------------- ------- -- -------------- -------------------------------------------------------------------------------------------------------------------------------------- - -------------------------------------------- --------- --- r- Final inspection Date 3-` -: J -------------------------------------- - .1`------------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M A`'