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FOR OFFICE USE: �� F APPLICATION FOR SANITA TION PERMIT --- (Complete in Triplicate) Permit No. ------------------- This Permit Expires i Year From Date Issued p bate Issued _9-: 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 No7 5.49 and-existing Rules'and Regulations: 1 JOB ADDRESS/LOCATIO L_, - - � 5�3_,e .� ------------- _ - - S TRACT ...... Owner's Name ---- ------CENSU - - - ----------�---- _"---- Address --------P one City Contractor's Name - _ _"--- -- - ----"--"-- Installation will serve: � - Phone ______-_---_"_""__ Residence artment House,[] Commercial:❑Trailer Court ❑ Motel Other---�----------f umber of living units:___"_�__.__ Number of bedrooms ��_-" Garbage Grinder -------- -- Lot Size ._9' -------- Water Supply: Public System and name Character of soil to a depth of 3 feet. Sand'Q ,lt. _Private ❑an Clay ❑ Peat Sand Loam Hard i' yes, Clay LOOM.El P Adobe [] Fill Material ------------ If es - (PYot plan, showing size of lot, location of system inrelation 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 TANKhi \ [ ) Size -------------- Liquid Depth --------------------------- Capacity ----------------- Type ------'-------------- Material---------------------- No. Compartments Distance to nearest: Well --"- I�" _ --- W LEACHING LINEIM -----------------------Foundation ---------------------- Prop. Line -------------------- No.C) of Lines ---- ------------------- Length of each line____----------_-- -- - - - Total Length "---•=------------•-- � 'D' Box ----- --- T I ype Fitter Materia!__-_ -_-----_----_Depth Filter Material _-_ ---- -" _ Distance to nearest: Well ___ -! _ -----"" - -__ Foundation SEEPAGE PIT Al - - ----- ------ �----- Property:. Line_ • ------------•--._.----- ) Depth ---------------""--- Diameter __ Number --___--- " --------- Rock Filled Yes p No ip - --------- Water Table Depth --------------------- --__-.---_-----_--_ -----,---- --- Rock Size --------------- - ----------- .Distance to nearest: Well __ "-"!_- i REPAIR/ADDITION(Prev. Sanitation Permit# -------•------- I - Foundation -----------" "-- -- Prop. Line --------------- - .. Septic Tank (Specify Requirements) ------------- �� pate ---------•-----•-" " -------------1 ----------------------•------------------- ..._-------- Disposal Field (Specify Requirements) ---------- ---- ,�. - ------------------------------------------------------ ----._ ----------I___ Draxisting 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 liven- 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 r as to b me subject to Workman's Compensation laws of�ICafifornia." p y an y person in such manner Signed - ----- ----- = --------------- ------ Owner " --- By ---- (If other --- i Jitle r than owner I } -` FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - BUILDING PERMIT ISSUED --------------- f=__ __' ;:: ==_. DATE � �s"�_ ADDITIONAL�COMMENTS __- _ _- • .c--- i , '_ w.. - ---- ------------------- --------- �I -------------� -- ----------------------------- ---- ina inspection by: _ , ---- - - --------- - --------_'i------------------------- Date ..-+ ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H,9 —1-'68 Rev. SM