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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _...,.. .. r........ Permit No. � �:.. (Complete in Triplicate) .................... .................................... -- Date Issued ..................... ......... ...... Thls Permit Expires li Year From Date Issued Application is hereby made to the San Joaquin.Locol Health District for a permit to construct and install the work herein described. This application,is made�ln,complion6e'w"fh-.'Cbut)ty'Ordinance No. 549 and existing Rules and Regulations: .. .......................... �d h�I .. .o. 6i..4. ... G....�................. CENSUS TRAGI JOB ADDRESS/LOCATi ........................... ...� -•- - Owner's Name ..... 4J.....••--........ E :.......................... ............---- ..................Phone ... ................................ Address .......I........�:�Q� D �F 1 �.Q=...... ! .................... City ..........................................................._................ Contractor's Name ..... ?40 U .... .............. License # ........................ Phone .............................. Installation will serve: Residence 0 Apartment Houseo Commercial Trailer Court ❑ 4 . Motel ❑Other............................................ Number of living units._-)...... Number of bedroom.,_.�.......Garbage Grinder.. Lot Size �CT�.Cr��' �/ Water Supply: Public System and name ............... :.......... ........... ...........................................---.......Private Character of soil too depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy 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 if public sewer is available within 200 feet,) PACKAGE TREATMENT j ) SEPTIC TANK{ I ) f, Size................................................ Lic�ld Depth .......................... �l Capacity .................... Type ..�_................ Material.............----•-•-- No. Compartments ' 4 Distance to nearest: Well ...:................................Foundation ...............:...... Prop. Line ...................... LEACHING LINE ( J No. of Lines ...................'... Length of each line..................-.......•-- Total length ............................ E ' 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................. Distance to nearest: Well ........................ Foundation ........................ Property Linei........................ . : t Water Table De t 3 iamete .: --w-Number- --':�. --•................ Rock Filled Yes ❑ No Q. SEEPAGE PIT De th .t., [ j p P .... .......... ...............................Rock Sizet...........................---- o Distance to nearest: Well ........}................... Foundation .................... Prop. Line ...................... ............ s REPAIR/ADDITION(Prev. Sanitation Permit# ........ -••-• ........................... Date ........ .........................) � y k Septic Tank (Specify Requirements) ................... ... .....................................................1 t Disposal Field (Specify Requirements) -.`rf - , ' ';7 '� •-- _ ............................................................................:.................... ...................................................................... _. ...•-•-•------...... .........---•---_........--•----:---...................•...---.. . IDraw 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 licew sed agents signature certifies the following: "I certify that in the performance of the work for which this permit 61issued, I &halil not employ any person in such manner as to become subject to Workman's Compensation laws of California." ;.. Signed ........................ --... ............... ... -- -- .............................. Owner ..2 ......... -- ...... Xitle 4� . ........................ (If oth n owner t f PARTMENT USE ONLY APPLICATION ACCEPTED BY ... .. ...... ... ... ...........•...........I.......................... ...... DATE ..... —../ y ............... BUILDING PERMIT ISSUED .... ... .. ...... .. . . . ....... ........................... ........ DATE ... _..................... ....... ................ ......... ADITI NAL COMMENTS . ...... _ .. .... . .......... .•---................._....-•---------..................................................._...............---_.... F.-::4....._..._ . ... ................. ....................................::::.....................I.......................... ............................... :.............. ....... .. ........ .. ..... . ........ .............................................. ..... .... .........Date Final Inspection by. --. ... .. .. .. ...........................• •-.t("��•�-j��................ N AQUIN LOCAL HEALTH DISTRICT F_ H-13 24 1.'68 Rev. 7172 3 M