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FOR OFFICE USE: �-- PPLICATION FOR SANITATION PERMIT ,�/ ----------------- (Complete in Triplicate) -,? Permit No. rub-,,�/z -------------------------------- ----------------------- --------------- This Permit Expires I Year From Date Issued Date Issued __ a--Td 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/LOCATI - 5� -__ s yt ea --------- ------ CENSUS TRACT Owner's Name _____________ _ 1 -------- ---------- ----------------- Address ----- --- Phone - Address ____._----1-p�� ) City -------------------------------------- •----/-- - ----------- - Contractor's Name ___ --_____.License # J�j____---- phoneI�6._3�_ 4�a7 lnstallation will serve: Residence ❑Apartment House❑ Commercial jTrailer Court F1j I Motel []Other ''`` F Number of living 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 1] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ f 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) K) PACKAGE TREATMENT f ] SEPTIC TANK Liquid depth _________________________ U [ ] Size j Capacity I------------------- -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 Filter Material --------------------Depth Filter Material _______________ Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------•--------••--- SEEPAGE PIT [ ) De th Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 0 Water Table Depth --------------------------------------- -------Rock Size - Distance to nearest: Well ----------------------------------------Foundation -------------- 4---- Prop. Line --------.----•-- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------•------•--_-,'} Septic Tank (Specify Requirements) -----------__________ - ---------- --------------------------------------------- Disposal Field (Specify Requirements) _____________ _ _ -------------------�-- - - --/- f 3"X 2-S ` -----•--------- -----f -------------------------------------------------- (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 as to become subject to Workman's'Compensation laws of California." Signed----------------------- ------------ -- ----------------------------------------------- Owner --------- -------------- BYL- Title ------------------------- (If h r than owner) --- ---�------------ FOR .DEPARTMENT US,E ONLY APPLICATION�ACCEP�TEDDisBUILDING PER = e DATE a ------------------ ------------------------------------------- ----DATE ------------ lTIONAL COMMENTS --------------- --------- ------------- ------•----------------------- ---------------------------------------- ----------•---------------- ------ -----= ---- -------- ------------ ----------- ----------- ---------- ----------------- ------------------------- ---- ------Final Inspection by ---------------------------- -------------------------------------------------- : ___ ------ -- ----------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M