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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .. (Complete in Triplicate) Permit No: e--------- This Permit Expires 1 Year From Date Issued Date Issued --------------------- ------------------_----_--------- Application is hereby made to the S Joaquin Local Health District for a permit to construct and install the work herein I described. This application is made i 'SoViiance with County Ordinance No 549 and existing Rules and Regulations: - JOB ADDRESS/LOCATION-.__1:,�_?--- -- - -------- -------- = ------------------ _x-----------------CENSUS TRACT -------------- ----------- Owner's Name ------- ' "/ r - Phone- _&- f -------- Address �J o Address __.._�--�_,-_ ____-- -- -- _ —Erty— � � L - __-- Contractor's Name ------ ----- -----_---------- ----------------------------------------- -------------------------------------- =-------.License # --------- ------ Phone ...... { r Installation will serve: Residence $Apartment House ❑ Commercial [-]Trailer Court i❑ Motel ❑Other ---"�---------------------------------------- Number of living units-----I----- Number of bedrooms _�P'-------Garbage Grinder __-_ -._ Lot Size -----------y - ----------- Water Supply: Public System and name ----- Private ❑ Character of soil to a depth of 3 feet: San ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam E] Hardpan ❑ Adobe V 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 see age pit permitted if publi ks available within 200 feet,) (� PACKAGE TREATMENT ( ] SEPTIC TANK Size__ _ Att `� Liquid Depth __ __,_-__ } -------- ------Capacity/d<4_Q_____._ Type fV e Material lJy! No. Compartments _ 2 °v --Foundation /-� --- Pro ---� _--_....-- ". Distance to nearest: Well _____��_Q_�__________ / --- p. Line�__ Tota! Len LEACHING LINE No. of Lines __-_�______________ Length of each, lin --------_ _a -__ gth _./7.�._______,___. 'D' Box ._.r/_ Type Filter MafierialS /�C-_._Depth Filter Material -1 --______________________ __________ Distance to nearest: Well ____ Foundation ___ �_3.... Property Line ___--- _---_-- A t SEEPAGE PIT [ ] Depth �Taie _: _ __ _� Dia eter N mbe ____ ___ Rock Filled Yes No ❑ Water Dep h ------------ --- Rock Size { " zg/ Foundation d� Prop. Line . j f Distance to nearest: Well --_----Ile ------ ----- _ (--------•--•- REPAIR/ADDITION(Prev. Sanitation Permit# ______________________ ---- Date------------------------------------ Septic ________,____ --Septic Tank (Specify Requirements) -------- - ------------------------------------------------------------------------------------------ --------------------------- DisposalField (Specify Requirements) ---------------------------------------------------------- --------------------------------------------------------------•----------- --------------------------------------------------------------- --------------------------------------------------------------- ----------------------------------------------------------------- ------ -------------------------------------------------- ---- --- -------------------------------------------------------.-------------'------------------------------------------------------------------------ (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 perf rman of the work for which this permit is issued, I shall not employ any person in such manner as to becoM7& �e t to orkm s Compensation laws of California." F Signed = --- Owner .' -------------- -----::___:------ By ---------- - -- - ----------------------------- :; i ------------------------- -Title --------- -------------------------------- ----------------------------- (If other than owner)f . F E RTMENT USE ONLY It APPLICATION ACCEPTED BY ------ - -------------------- DATE --- . _7- - BUILDING PERMIT ISSUED ---T- ---------- --------------- --- 7 ---DATE ADDITIONALCOMMENTS --- -------------------------------------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------- --------------------------------------------------- ------------------------------------- i Final Inspection by: - Date y9� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M