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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued Date Issued .__7_-__7---7- 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: JOB ADDRESS/LOCATION --- ------------------------- CENSUS TRACT Owner's Name _10-4/4 - - --------------•----------------------------- ------------Phone.. _. -------------------- Address 'maAddress .---- -- L��" ._ Cit Contractor's Name ��. ----.License # ------- ------------ -- Phone ---------------------_----- . -�a ------- --- ' 'r Installation will serve: Residence 5Q Apartment House❑ Commercial ❑Trailer Court Motel ❑Other Number of living units..---/------- Number of bedrooms ----2------Garbage Grinder ___________ Lot Sizeb____-------__ _ -------- Water Supply: Public System and name -------------------------------- ___________________Private.a] Character of soil to a depth of 3 feet: Sand❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.m 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.) W NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size-------------------------- --------------------- Liquid Depth ------------------- { Capacity ----------------- Type -------------------- Material--------- ------------ No. Compartments •------•----• LEACHING Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------- -------------LINE [ ] No. of Lines _______________________ Length of each line------/------------------- Total Length --------------- _._____._--.- _ 'D' Box ___________ Type Filter Material ____________________Depth Filter Material ----------------------------- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _____...._ - ------------- SEEPAGE PIT [ ) Depth ___________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No �❑ Water Table'Depth ------------------------------------------------Rock Size Distance to nearest: Well ---------------------_-----------------.Foundation -------------------- Prop. Line ---•--_---- REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date --------------_----_- Septic Tank (Specify Requirements) -------------------------------------------------------- Disposal Field (Specify Requirements) _ A r -------- ----- ---------------------- f a ------ ---------------------------------------- (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 G as to bec a su 'e0 to orkman's nsafiion laws of California." i Signex. - i Owner By ---------------- ----- Title ----------------------- --------------- (I of er than owner! 4 k FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - _-- -- -.r,.c----------------------------------------------------------------------------------- DATE _. _` 7/ BUILDING PERMIT ISSUED -------------- - - -- --------------------------------DATE ------------ ADDITIONAL COMMENTS --------------------------------------- - - --------------------------------------------------------------- ---------------•-------------------------------------- ----------------- - - - - - - - --------- -------------------------------------- -- ---- - - --- ----------- --------- Ina Inspection by: -- - _--- _-- ----------------- Date .�-1.-��--- ---------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M