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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ............... 77 Permit Na. ...._7 —1. (Complete In Triplicate) ............. ... ............... ------ ThisPermit Expires 1 Year From Date Issued • Date Issued 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 ------ _.Phone ........................... Address /..✓r. �.. ....................... City ... .. ". . ...--........_.........•_..............--..---....---•-- r a Contractor's Name ........ ...License # Phone Installation will serve: Residence Apartment House fl Commercial oTraller Court 0 Motel ❑Other ..:.................. = = Number of living units:......L.. Number of bedrooms ......Garbage Grinder ------------ Lot Size .....................:... . Water Supply: Public System and name ....-............-.........•...............-•-------------------.....--•----------------------- -•------------...Private ❑` Character of soil to a depth of 3 feet: Sand'❑ Silt❑ -Clay [] - Peat❑ Sandy Loam Clay Loam ❑ is Hardpan ❑ Adobe'[] Fill M6terial ------------ If yes, type ............................ - tA( iPlot ;pian, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.[ NEW INSTALLATION; (No septic tank or seepage'pit permitted-4 public-sewery s available within 200 feet,j \. PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size................................:............... Liquid Depth .._. ..................... 0 Capacity ..-- -•-- ..... Type .................... Material.._...-----_----_- No. Compartments ........-•........ :.... � Distance to nearest.- Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE [ ] No. of Lines ................... ..................... length of each line------------------------------ Total Length ............................ 'D' Box ............ Type Filtdr Material ....................Depth Filter- Material ......_..........:_._ Distance to nearest: Well ........................ Foundation ....--- .____--_ Property Line .....................,_. SEEPAGE PIT [ ) Depth .................... Diameter .........._ .... Number ...__.:__-.........._._-•---- Rock Filled Yes ❑ No [j Water Table Depth Rock Size Distance to nearest: Well ........................................Foundation ----- .............. Prop. Line ...._...._...._...... . REPAIR/ADDITION(Prev. Sanitation Permit q6s -------------------------------------------- Date __................................ ) Septic Tank (Specify Requirements) ...... = — Disposal Field (Specify Requirements) - ...... .......6.. �-�-�._.ar��.-„e._.�_ -------------------------------------------•• ---------••----------------------••-----------------------------•-••- -----. -----------...--------------------- .................. (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that thwork will be done in accordance with San Joaquin e 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 as to become subject to Workman's Compensation laws of California.” Signed --------------------------------- ••---•----•- ................ .... ........•--:..._ Owner By .................. . ---- ................. ... /'- . ._. -: Title _. . (If other than owner) ........................... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY....................... ..... ._. DATE .._..._33. ..a.... . BUILDING PERMIT ISSUED ................................................._ ...............--•--------- ....._......--- DATE ..---.... .......... ADDITIONAL COMMENTS ...--•-------•........ ........ - ........... ------ ............................... :...-----••-_• ••--•-----...----•--------------------- ------• :....::................-...... • ........ Final Inspection by. .............._. .............. ......... r r ----------- ................. ---Date __Z. ............... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241.•68 Rev. 5M 71723 M