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FOR OFFICE USE:. �� 0` �AP'PLICATION FOR SANITATION PERMIT Permit No. ----- ----------------------------- --- -------- (Complete in Triplicate -----------=-------- -- --- ----- --- --------- - p Date issued _�"�_�•�Q E This Permit Expires 1 Year From Date Issued ------------------ Application is hereby made to the San Joaquin Lacal 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 -C_T r--------�-----j- -•�---------- JOB ADDRESS/LOCATION �_��1-- .-'>-'-"- -r' --- ------------- - Phone Owner's Name -----/_ 6 City -- ------------- -- -- Q- ----- - -- Address ... - ------- ----- ---- --- -• --------- --------------------- ----------- tez,7 Phone Contractor's Name ---------- ---- License # --- ----_=-- -�� " � r, Installation will serve: Residence';Apartment House❑ Commercial ❑Trailer Court Motel ❑ Other -------------------------------------------- [ 3 Garbage Grinder .N0----- Lot Size __�-54---��7---------------- Number of living unifis:-_- -.----- Number of bedrooms _.-_----•-- - - - ------------------------- PrivateJ Water Supply: Public System an name ---------------------- Character of soil to.a depth of 3 feet:. Sand'❑ Silt❑ Clayr❑ . Peat ❑ Sante Loam ❑ Clay Loam ❑ � _..- Character to,a e . �.�t... ancl Hardpan ❑ Adobe .Fill Material ____________ If yes,type ------------------------------------- ` IPlot plan, showing size of lot, location of system in relation to.wells, buiEdings, etc. must be placed on reverse side.] it NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewir is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK;[ ] _ Size_ r l� ---------------------- Cap _�_. Liquid Depth _ - ------. Ca acit -----.,-- Type Material � No. Compartments -__ -..__..---- Distance to nearest: Well __-__7 -_--------------------Foundation __._.� -- Prop. Line __ ----_.---•- r ` ___ Length of each li e_:--��------- ----- Total Length _r�-.�f�-----------•---- LEACHING LINE [ ] No. of Lines _.--_______--__---_ ,J 'D' Box j Type Filter Material/��--___-- ---Depth, Filter Material ___�0- ---- ----- ----• ----�� Foundation. - - ---- --- � p ty` --- Distance to nearest: Well - �-- 1 Pro et Cine=- =-- ` ` SEEPAGE PIT De th __ Diameter ---------------- Number ----- ---------------------- Rock Filled Yes ❑ No 0 I O,INater�Table Depth Rock Size -------------------------- ----- Distance to nearest: Well ----------------- -----------------------Foundation -------------------- Prop. Line _. I REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------ -------------- Date ------------------------------ Septic Tank (Specify Requirements) ----- ----------------------------------=----------------------------- -------------------------------------- Disposal Field {Specify Requirements) _____________ -------------------- ,I �_ ---------------- - _ ----------------------------------------------- - -_- —=-�.. --- -------= - _ - --------------------------------------------------- -- ---- --- - ---- -- --- -------------------------------------------------- ------------------------------------- ----- --------------------------- (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 shCrll not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed -------=--�- Owner - E --------------------- k .�J� d B rE- Title -If other than o _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY __ -- ------ -------------. DATE y -�. �Q---------------------------- - DATE ---------------------------------------- BUILDING --- ----- -------- -------------•---- BUILDING PERMIT ISSUED ------------- - --- --- " - ---------------------- ---- ------- -------------------------------------------- ------------------------- ------- ---------------- ADDITIONAL COMMENTS ------------- -----------------------=------------------------- - ---------- -- ----------- -------------------- --------- ----------- ------ - --------- ------- - - --------- ------------ Date Final Inspection b --------------------------------- -------------------- ------ -- ------- CA EALTSAN JOAQUIN L H T T E. H. 9 1-'68 Rev. 5M