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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7- 3�y 7 - - -- ------------------------------ e� (Cpmplefe 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 per 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 AD . � _. - -------- ------CENSUS TRACT ------------.............. Owner's Name _-- _. - ----- --Phone Address 4 - =7 City - - �1�.-- --- �(cil - L Contractor's Name __._ �_ icense .//7.�. O__ Phone -----------------------'`--_ Installation will serve: Residence Apartment House°[„Co / er i I-❑Trailer-Court i:E]fJ � Motel ❑Other2 Number of living units:-------_____ Number of bedrooms --- ----Garbage'-Grinder .___�-_ Lot Size ____ C--' -�- Water Supply: Public System and name ------------------------------------------- - Private - Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat❑ # Sandy,Loam ❑ 'Gay Loam Hardpan ❑ Adobe ❑ Fill Material ______ .... If ye`s, type-________{____-__:�.__'_a----._: (Plot plan, showing size of lot, location of system in relation to wells, buildings; etc.- must be placed=on�.4-everse-,side.) NEW INSTALLATION: (No septic tank or seepage,pit permitted if Jublic sewer-W va ailable within 200 feet,) i PACKAGE TREATMENT SEPTIC TANK Size__ ` q Depth _. Liquid De _ Capacity D'00--_ Type Material---- ------- No. Compartments _______ _ _ ------- Distance to near t: Well ----------- __ __Fou dati Prop. Line _____S_ LEACHING LINE ] No. of Lines ._____-____.____ Length of each line____._ _�__ ___ _________ Total Length __1 .. _�-- 'D' Box -___. -__-- Type Filter Material ___ ___ ----Depth F ter cterial ____ __g________________________(.-. .- Distance to n7epth a t. Well ______�a_ _ Foundation ------�._ _� _______ Property Line --__-_-5. ____ Rock Filled Yes No SEEPAGE PIT [ j Depth / -- Diameter ---- --- - Number ------- ----/--�- r +� ❑ Water Table ------------=Z;Z-= - -- ----------------Rock Size --- Distance -Distance to nearest: Well --- --- ------------------Foundation ----��---------- Prop. Line ---- ---------•---- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_------------------------------1 Septic Tank (Specify Requirements) ------------•------•---- --------------------------------------------------------- Disposal Field (Specify Requirements) ----------------------- ------------------------------------------ --------------------------- ----------- ---------------- -----------•--------_-- r --- --- -- --- - - - -- ---------- ----- {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 --------------------- - --- -- q-7 -- ------------ Owner- , -By --------- �/ L - ---�-_ _Title (If other than owner) FOR DEPARTME T USE ONLY APPLICATION ACCEPTED BY ._ ____. DATE ._.�T�"�--�'. ---------------------------------------------------------------- --------- BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE:_------------•---------•- ------ ADDITIONAL COMMENTS ----------------------- ----------------------------------------------------- --------------------------------- -------------------- -------- -•---------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- -------------------------------------------- ----------- --------- ---------------------------------------------------------------------- -------------------------------------------------- ------------------------------ -- ' -- --- - - - - - ------------ - ----- -- Final Inspection by: `-- _ --------------------------------------- --------- ------ ---- --Date ---------------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 .1-'68 Rev. 5M