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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No:."7-�-_- -------- -- ----------------------------------------- (Complete in Triplicate ------------------------------ Date Issued --Z"7;-_7� - - 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: CENSUS TRACT --------------•----------- -- ----- , JOB ADDRESS/LOCATION .. �{-' � � �X�---- 1 _ �5 ------ ` ------ ------------------------------------ Owner's Name ---- --`-�-- -------------------------------------- f' Cit ----------------------------- ... Address �-d2----= '' - --e � -- - --------- ---------- ------------ • Y -- Contractor's Name / J � f reI---------------------- ----------License #�� Phone Installation will serve: Residence ;j Apartment House❑ Commercial ❑Trailer Court ,❑ ' Motel ❑Other -------------------------------------------- Number of living units:--- Number of bedrooms d --__.Garbage Griner- *f- -- Lot Size 7 , 0�. Private ❑ Water Supply-.-Public System and name -------r _ Y Character of soil to a depth of 3 feet: , Sand'D Silt El Clay ❑ ❑Peat Sand Loam ❑ 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 '+f ubiic sewer; available within 200 feet,�)i= � Size_ Liquid De Depth -------.- PACKAGE TREATMENT [ ] SEPTIC TANK 96- �~-- - P G' - T e _��____ Material- �Z�'- No. Compartments -_ ----------- Distance -_---.. - ---- Capacity��. ---- YP �� Distance to nearest:'Well ----------------------------------- Foundation X!, _?--"--------- Prop- Line Z-4------------- - j Total Len th/:-� - Length of each line___- g LEACHING LINE No. of Lines ----- ---------- - Al D' Boxy Cype`Filter Mafierial/ _,/ Il7 -_ -Depth Filter Material ----4-;- .`" / f r ____ Property Line _ Distance to nearest: Well ___1-------" ---__ Foundation _ ____.____ -- SEEPAGE PIT Depth -"rP1--- ---- Diameter ��_____ Number .____1 ____--_---- --. Rock Filled Yes No i❑ -------Rock Size%---� --- ---------------- Water Table Depth _-- _-�----------------------------•- — 'g ,� ` __ Prop. Line _4-------- Foundation _ ----------------- Distance-to nearest: Well ______�'--= --- --�------' W Date ---------- ----------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- `- - ----------- Septic Tank (Specify Requirements) -=------------------- ---------"•• Disposal Field (Specify Requirements) --_-------•--------- ----------------------- ----------- ---------------------------------------------- -- t ------ ------------------------------------------------------------------- -------- -- = ----------- --- - '--- g q ' (Draw existin and required addition on reverse s d e 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: w 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 Compensatiop. laws of California." Signed ---------------------?tow.nerj) ` Owner ------------ ----------- - ----- ----------------------- ----------- -- --- - �'4 - --------------------- Title .-----_ ' '�.------------------------ ----------- (If othFOR DEPARTMENT USE ONLY DATE -------- APPLICATION ACCEPTED BY -- DATE ----- BUILDINGPERMIT ISSUED ----- ------------------------------------------------ ----- -------- ------ ADDITIONAL COMMENTS ---------- ------ --------------- --- ---- ----q - --------------------------------------------------------- ---------------------------------------------- --- --- ----s---------------------------------------------------------------------------------------------- ----------------------------- ---------- ------------------------ - ----------------------------- --- Final Inspection b --- ----- -.Date - ------------------------------------ --------------------------------------------------------- ---- - SAN JOAQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'68 Rev. 5M