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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------------- --- -; ---------------------- (Complete in Triplicate) Permit No. —7:_�_ . T ------------------------------------- -------------------- -------- ------------------------------------------------ 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: I JOB ADDRESS/LOCATION ___.___ _ _-__ _ '' ,j~- C'L1'��C I/ 6iJ ? SU TRACF �`_ 4-1 Owner's Name - ------- .eV Q ......_ 1 ---------------------- --------- Phone - Address �` P!/ City _ G Contractor's Name ----- !_�- l c.� License Phone ___ �d t -: Installation will serve: Residence ❑ Apartment House,❑ Commercial:❑Trailer Court ;{] Motel ❑ Other . Number of living units:------I____ Number of bedrooms �----__Garbage Grinder ___-__ - Lot Size _________________ __________-____________ Water Supply: Public System and nc!me --------------------------------------------------------------------------------------------------------------Private Character of soil to a depth of 3 feet Sand F Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam ,0 Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ____-_____________________ a (Plot plan, showing size of lot, location of system in relation to- wells, buildings, .etc. must be placed on reverse side:)— NEW INSTALLATION: ,1 {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} 0 PACKAGE TREATMENT { ] SEPTIC TANK[ ] Size-------------------------------------------- Liquid Depth -------------_------------ Capacity - = --------------- Type ------------ Material---------------------- o. Compartments -----------------_ Distance to nearest: Well ------------------ -----------------Foundation -- ------------------- Prop. Line ---------- _----- LEACHING LINE [ ] No, of Lines`` ________________________ Length f each line----------------- __._ Tota! Length ____-_____________:.__..____ l 'D' Box ----- ----- Type Filter Materi --------------------Depth F- er Material ------------------------------ ----------- M to nearest: Well ___________ __________ Foundation __. __-____________--- Property Line. _______-_--_____-_._.___ SEEPAGE PIT { ] Dep#h -------!_---_____, Diameter _______________ Number ---_- _____________________ Rock Filled Yes ❑ No i❑ r Water Table Depth --------------- --------------------------------Roc Size ---------------- --------------- Distance to nearest: Well ----- ----------------------------------F ndation -------------------- Prop. fine -.-------------------- i REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------._.________} Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- ------------ Disposal ----------Disposal Field (Specify Requirements) ------------------------------------------------------------------- --------------------- --- N ---� --- - �---':ice ---------r - l ,�------- 1 N �-------� CS' 11✓ ` ss _ {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." I s Signed ------ - -- -- -- -------- - :--------- BY Owner -- -- ---- ----- -- w ----------------- Title ---- ----- --- ------------------------------------------- (if other the , FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----Tt_ P----------------------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ________- i� A/--------- _ ---------------------------------------------------------- ------------------ DATE ADDITIONAL COMMENTS _. ------------------------------ --------------------------- i -------------- ------------------ -- ---- -------- l ---------------------- ------------------------------------------ ----------- - -- ------------ ----- -- p ma Inspec i -------.Date ----- r ._ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. SM