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FOR.OFFICE USE. ° APPLICATION FOR SANITATION PERMIT � � y y ` .t, ..0.---- --- � -7 Ll,� M Permit No. (Complete in Triplicate) � .. ............... �. ......... .. .. ...:..................................................... This Permit 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 _ A Address ------------------•..._._.__..:�•. ...... city ... ... Contractor's Name ................... .... .-- •--••--- ------ --- �.-'--.-..License #!�'V-3.�3_.._. Phone .�.(V...T.�7Q7.... Installation will serve: Residence tXApartment House[] Commercial ❑Trailer Court i❑ Motel ❑Other ...............•---•------------------------ Number of living units:..-. ._..... Number of bedrooms .._...Garbage Grinder .... Lot Size .....71--- K.1;1k_1.............. Water Supply: Public System and name ..........................••_. .......................... ...................Private 0 Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam D Hardpan ❑ Adobe.r�k Fill Material ............ If yes,type .........................._ {Plot plan, showing size of lot, location of.. system in relation to well`s, 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,) PACKAGE TREATMENT -SEPTIC TANK Size_......_....J__.____.,................... } I ) t ] -----= liquid Depth .......................... Capacity .................... Type .................... Material...................... No: Compartments Distance to nearest: Well ------................................Founclation-,.......±........... Prop. Line ..................... LEACH INGL iNE"' { ] No. of Lines ........................ Length of each line............ ........... Total Length ----------------------------- V ---------_-_ •-'D' .Box ......... Type Filter Material ................. Depth Filter Material - � Distance to nearest: WeII ........_......._:...... Foundat on_:_:: :::.::::::.-._�`. Property Line ........................ SEEP,4GE PIT' L?1.4 .,Depth _... _-----------. Diameter ._....... Rock Filled Yes ❑ No 0 r ----•----------. Number ..._..-•--------- f era WatTble Depth th p ................................................Rock Size ................................ �. —Distance to nearest: Well ........................................Foundation ...:................ Prop kine . 3 REPAIR/ADDITION(rrev. Sanitation Permit# ............................... .... ....... Date .:.:...: Septic Tank (Specifq Requiremnts) ---------------------.._*1 ... - Disposal Field`-(Specify Adquirements) ..................0 :_ ...-----._ d.:..... 4 +y �• , . . ......... ................................... _ . + t kJ -----------------•--- ._....--- _ -- •--•---- �, E (Draw existing and required addition on reverse side)' I hereby certify that-.I-have prepared this application and that Ithe work will be done in accordance with San Joaquin County Ordinances;,Stafe`Laws, andRules ,and Regulations of-`the" San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: ,-,d N "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed-: :......:_ .... . .. . Owner ' ... ----------------------- By ...................... ` • Title ..._ e------------------......_..._._._._.__...._......_. r {If other th caner) FOR DEPARTMENT USE ONLY .:APPLICATION ACCEPTED BY -• ........... ....•... DATE � -------- i BUILDING PERMIT ISSUED DATE ........................................... ADDITIONAL COMMENTS ........... -Q.....'.....4.. ........ -��= 'Jd.._........ .....................•--•-•---...............--•--•-- ................................................ _.... ...----•-...:..................................... '............................................__.......................................... s _._:..-----•--------------------/- ---•--- -----_ ---------•- ._........- ... Final Inspection by -_----•.Date *- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 13 241-'48 Rev. 5M 7172 3 M