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FOR OFFICE USE: ' a APPLICATION FOR SANITATION PERMIT _..p_. .:�......_... f • Perm#�No: (Complete to Trtpllcatel,. Thls Permit Expires 7 Year From Bata Is . _. _- . .............................. sued Date Issued ..Z.:..__,...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 CounnhE Ordinance No. 549 and existing Rules and Regulations JOB ADDRESS/LOCATIO �.... ! r �_ ::.: -'c."`'�'�_... ....................CENSUS TRACT ..._... ................ Owner's Name h l• Address one ..._..._ .... ...... . ..�---.._..._ .. --- -- City _ Contractor's Name 4" .�.. License # .......................... �� Phone -' .�„? a Installation will serve: Residence Apartment House 0 Commercial EjTraller Court Motel {]Other ------ --------- -- A i Number of living units:---- Number of bedrooms _.....Garbage Grinder .' Lot Size__' ._.� .75� . # Water Supply: Public System and name ......................................Pr#vote Character of soil too depth of 3 feet: •Sand[] Silt❑ Clay b Peat❑ Sandy Loam o Clay Loam o Hardpan 0 Adobe Fill Material ............ If yes,type Mot plan, showing size of tot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: r_ (No septic tank or seepage pit permitted if publE.c sewer is avail ble within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK Size -------- ' ----- Liquid Depth w Capacity/ ± Materia _ Compartments ---- ,-- ---.....-- Distance to nearest: Well _ -..4�e�____Foundation ... f ... --- Prop. Line _` .............. LEACHING LINE No. of Lines -- _--__- Length of each line.._- _ . Total Len th ./A..00 . 'D' Box ../.-.-- Type Filter Material - _Depth Filter Material .._ 'c Distance to nearest: Well. _ (- Foundation r 5�` ........... l•---�----�.•. Property Line ---... r SEEPAGE PIT Depth C;7_Z.— .... Diameter -�-r•-- Number ----- ---------------- Rock Filled Yes, ' No ❑ 1Nater Table Depthr ..--•• ------------•------- -Rock Size ....... Distance to nearest: Well--- _-— i . ..�.--• _•-Foundation =_hC _._...... Prop. tine AS................. REPAIR/ADDITION(Prey. Sanitation Permit# ......................... .. :..:..:........ Date ----- ...... ,-•-_-........ ) Septic Tank (Specify Requirements) I Disposal Field (Specify Requirements) ............... . : . ..... ' - -----------------••---- _.---------------------------- ------- •-- - (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 accordancewith Sao Joaquin County Ordinances, State laws, and Rules and Regulations of the .San Joaquin Local Health pistrict. 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 -- ---.a.............. (If other than owner( DE RTMI:NT.t1SE ONLY APPLICATION ACCEPTED BY _._. .. - DATE _.. .-.fid.-, �.- BUfLDING PERMIT ISSUED ........ --- ------ _ DATE . •-----. ADDITIONAL COMM TS ._-_.. _.�. . -_ - -�6- -_.. --------... -•----------- E ----------- a - - - ........ ...................................... . ......•---•-••--_•-............. --- ---------• --------------................I...... , Final Inspection by: -- - __-_--. _ Date EH 13 2h 1-68 -7. . AN JQAQUIN L©CAL HEALTH DtSrRICr $ 7� 3M t C-3