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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No: --------------- --------- ------------------------- This Permit Expires ] Year From Date Issued Date Issued -.�T7--Z3- � 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/LO N JA ___ ` ; ' =— " -------------- CENSUS TRACT Owner's Name .---- ' ------------- --- -- ------------------ -------------- ------- ------- ----------- -- -------- one _ - Address ------- ---- ------------ -- r City ti.J -- -- - - -------- ---------------- Contractor's Name -. , Z ------ --- _� - License # X�3�� Phone Installation will serve: Resident ❑Apartment House❑ Com erdal:❑Trailer Court iNumber Motel [IOther of Iiving units------------- 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❑ r Sandy Loam Clay Loom 'E] i 1 t Hardpan ❑ Adobe 0 Fill Material -__-.- if yes, type°--------------_-- n+e }(Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc...must'+ be placed on reverse side.) \ r INEW INSTALLATION: (No septic tank or see \ p ge pit permitted if public sewer is available within 200 feet,) (PACKAGE TREATMENT [ j SEPTIC TANK'[ Size_T - _ --------- Liquid Depth �----- ------ \ Capacity _.� ®_- Typse�in.P.�-„� _ Material-- . No. Compartments _c �---.--------- Distance to neares . Well ---------- t'--------------------Foundation ----/_P_------------ -- Prop. Line -----.3'_----•- :LEACHING LINE [ No, of Lines �----------------- Length of each line-----4?0___------------------- Total Length f 6 - D' Box __ ---__._ Type Filter Material - � JZ- -Depth Filter Material Distance nearest: Well ------S -_--- r f ----- Foundation - ---- -Q---_____----'- Property Line _U-_•------------•_-,. f 'SEEPAGE PITj [ ) Depth p Diameter Number ---- ----------------------- Rock Filled Yes ❑ , No 0 L° Water Table Depth ------------------------------------------------Rock Size -------------- Distance to nearest: Well -------------------- Foundation ----__------ -- ------------•- - -------- Prop. Eine ----- - ----------•-- AEPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------____-- -- _- �"' ---- 4 Septic Tank (Specify Requirements) -------- ----___-.._ - t rDisposal Field (Specify Requirements) ---------------------------------------------------------- .- - ---------------------- --- T ------- ------------------------ ------------------------- ----- - -----`- - - kl hereby certify that I have prepared this application an and that the _' (Draw existing and required addition on reverse side) P P PP a work will be done in accordance with San Joaquin sCounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- ed agents signature certifies the following: i'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 an's Compensation laws of California." 3 Signed -------- I- ------- a - ner - ---- ----- ------------------- -- By --------- -- ---------- -----&2; _ :"Title (If other than owner) � ---------- --------�- - --- '- •�''�'`-FOR -DEPARTMENDATE . T..USE.ONLY 'APPLICATION ACCEPTED BF- ✓`�" 2 BUILDING PERMIT ISSUED -- ---- --------- - -- ---------- --------DATE ----------- -•------------ADDITIONAL- --- COMMENTS ------------ ------------------------------------------------------ I ------- --------------- -- ---------- ---------------- ....... ------------------------------------ -- # ----- ---- - ----------------------- --------------------------------------- rna Ins pectian by: --- - - ----------- - - - - -- - - - - - - - -- - - --- ----• ----------- ----------- -------------.Date - --- - - -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M