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} FOR-f :r iCE USE: APPLICATION FOR SANITATION PERMIT Permit No. �-------------•-- - ------ --------------- ---------- ----------------------- (Complete in Triplicate) ------------------------------ ----- -------- - 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. 7 CENSUS TRACT -----------------------•-- JOB ADDRESS/LOCATIONJ. US ------------------------ Owner's Name --- � --------------------------------------------------------------- Phone City, Address -- 10 ---------------------- ------------------------- S _7� License #1,;72 ----- Phone Contractor's Name Installation will serve: Residence Apartment House^❑ Commercial ❑Trailer Court ❑ Motel ❑ Other -------------------------------------------- r r 4 ' t l� AV- ----------------•------ Number of living units:-_f__..... Number of bedrooms ____--____._Garbage Grinder ___.-_ lot Size .___ --------------------------------- ------------- -----Private El Water Supply: Public System and name __________ .-------------- 10 Character of soil to a depth of 3 feet: Sand❑ Sift El E] Peat El Sandy loam ❑ Clay loam El 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,) PACKAGE TREATMENT { ] SEPTIC TANK'{ ] Size--------------------------------------------- -- Liquid Depth --------------- 0 Capacity ---------=----- -- Type --------------------- Material No. Compartments : .yam Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- ------ No. of Lines -------- Length of each line___.--_-------------------- Total Length ---------------- ----------- V LINE°- [ ]' - - 'D' Box ----1----.-- Type Filter Material ---------------------Depth Filter Material ----------------------------------"-------•- Distance to nearest: Well _______________________ Foundation ___ Property Line ------------------ .� SEEPAGE PIT [ ] Depth � - Diameter ---------------- Number ------------------------------------- Rock Filled Yes ❑ No ' WaterTable Depth ------------------------------------------------Rock Size -------------------------------- } Distance to nearest. Well --------------------------- ------------Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------------------- --------------- Date ----------------------------------1 Septic Tank (Specify Requirements) ------------------------------------------------------------------------------------ --------- ------------------ ` - ---------� /"/� i�-- /J` %l/ /fes' I Disposal Field (Specify Requirements) --------- -'---/ sI,`n ------------------------------------------------------------- - --------------------- ------- ------ -------- ---------------------- ----- ---- -- (Draw isting 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: permit is issued "I certify that in the performance of the work for which this , I shall not employ any person in such manner t as to become subject tt Work fan's Compensation laws of California." r SignedI ------------------------- Owner --ice ; '` Title -------- --------- ... ------'-, ------ ----- __------ - / (f,o`her than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---L�✓ ---------- -------------------------------------------- DATE � � ---------------- ----------------------- - BUILDING PERMIT ISSUED ----------------------- ---------- -------------------------=--------------DATE --- ADDITIONAL COMMENTS ---------------------------------- ------------- ---------------------------------- --- • - -------------------------------------- ------ ----- - - --------------------------------------------------------------------------------- --- ------------------------------------------------ -------------------------- --- -- -- - --- Final Inspection b ---___.__Dater ----- ------- - Y; -- --------------------------- e SAN JOAQUI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M