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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -------------------------------------------- (Complete in Triplicate) Permit No. .7-L-=_-__....... 5 ------------------------------------------_---------------- 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/LOCATI _: 7 '' ��l'..___:____._______._CENSUS TRACT __J. ............. Owner's Name = Phone Addresses--- -------- ------------ . City ------------------------------------------------------ Avo Contractor's Name _ (:•__ .License # -.1_�-g,- - -_ Phone ______________________________ Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court '❑ Motel ❑Other -------------------------------------------- Number of living units:------ Number of bedrooms _,3____..Garba_ge Grinder ------------ Lot Size ____________________________________________ Water Supply: Public System and name ---------------------------------------------------------- --------------------------------------------------Private Ik Character of soil to a depth of 3 feet: Sand'El Silt fl Clay ❑ Peat[j Sandy Loam -IX Clay Loam ] Hardpan ❑ Adobe ❑ Fill Material ------------ if yes, type ---------------------------- (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,) .V r l PACKAGE TREATMENT [ ] SEPTIC TANK+{} Size-V5--- _ ___ _______-____ Liquid Depth _/ ______ ___________ Capacity, `F _ ._ 1ype J___ Material__ .._----._ No. Compartments A— If Distance to neares Well -------------_fir___--------------------Foundation _- YJ_-____-_-_-- Prop. Line ---- .......... LEACHING LINE [ No. of Lines _____ _________ __ -_ -� - Length of each line_____��' �------- ------ Total Length _v-S- ___._ __________ r+ 'D' Box _ ___,--_ Type Filter Material -----Depth Filter Material ______ _ --------- _-------- �_______-_,__.. Distance to nearest: Well -----SO___r________ Foundation- -------t!............. Property Line .. .................. SEEPAGE PIT [ ] Depth ___________________ Diameter ________________ Number ---------------------------- Rock Filled Yes © No Q 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) ------------------------------•----------- --------------------------------- 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, II shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." i Signed ---------------------- --�(�- Owner BY - ---U'_-� Title : ---------------------------------" (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .,- A ----------------------- ------- ---------- DATE _p' _`--- -- - ------------------- BUILDINGPERMIT ISSUED ------------------ --------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONALCOMMENTS --------------------------------------------------------------------- --------- ------------------- ----------------- -- •------ --- ----- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------- - --- - - --------------------------------- Final Inspection by: --- ---------- - - - Date : " --------- I SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev_ SM