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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT _ ........................................................ Permit No, �'6 t .....................................I................. (Complete in Triplicate} `S•••• i This Permit Expires 1 Year From Date Issued Date Issued ...7...:x-.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 Co my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/ OC TION ,.... ..... CENSUS TRACT ........ Owner's Nome " 4 Phone { Address ..A..1'. .. ..... ... ...........'City . . Contractor's Name ... , .r-. -_.License # ' :.. ....- one ....... ........ Installation will servei ResidenceD Apartment House Commercial []Trailer Court �] . . . Motel ❑Other .........43.AZZ... _. 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❑ Clay [J ' Peat❑ Sandy loam Clay loam ❑ i Hardpan ❑ Adobe ,C] Fill Material if yes,type . (Plot pian, 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,J PACKAGE TREATMENT [ ] SEPTIC TANK j Size..:�......X-1.....�.+,..s�.................... Liquid.,Depth .f ..................... t "s I Capacity A TypeQ •. Material s No. Compartments `.. ......: .� Distance to neares#t Well ..........tee....................Foundation .JA............... Prop, Line ....�..� � ...........S LEACHING LINE . [ No,"of Lines f g � � ' ••---•.................. Length of each ilne....... ..... •----.. Total Length ....�.�?� ...............W 'D' Box Type � ...'r..... T e Filter Material ......t�..�,.....Depth Filter Material .....er..q............:.... .........:-•.z Distance to nearest. Well ...../..11...:......... Property .Line ....-��.......... Foundation .. .............. � SEEPAGE PIT [ I Depth ....................« Diameter ................ Number ..._...:.................... Rock Filled --Yea ❑ No. Water Table depth .:.......................Rock Size Distance to nearest, Well ........................................Foundation .................... Prop. Line ...................... G REPAIR/ADDITION Prev. Sanitation'Permit Date ......:J Septic Tank (Specify Requirements) !° Disposal Field (Specify Requirements) ....... — �.. t .. .. •....................I....................... ...-----........... . .------.................---.....I...---................-- ........................................................................ Z .......................................i............................... ............--•---••----......................•---...... Draw existingand required addition on reverse side} I hereby certify prepared that I have 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 Workma 's Compensation laws of California." Signed ...................................... ..... .............. ...�. ._...-' ...... Owner-......... . ........-�---�......... . ...---.................-----.. -- 13y ..................:...................... title .. (If other than owner) FOR DEPARTMENT USE ONLY 5 APPLICATION ACCEPTED 8Y 7 ...... .................. :... DATE,.:...�. ..........:..._.... .............. BUILDING PERMIT ISSUED ADDITION ............................................... .................................................DATE"=� `............... � AL COMMENTS ...................................................... 1 - :,... ::...:............. . ..........................................I...................................... ........ `r r Final Inspection bye ............ ..... ................ ..........._........:::.-..:......_....................... ......... ......... ' ........ . .. ..................................Date ..... :/..fl . .............. SAN JOAQUIN. LOCAL` HEALTH DISTRICT E. H.13 241•'68 Rev. 5M-. 7/72 3,M