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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..................... -------------------......................... This Permit Irxpires 1 Year From Date issued Date Issued Application is hereby mode to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance w^County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LO TION ' r 0 . --- ........................................CENSUS TRACT ................:......... Owner's Name .---- . . _ one --- ..... ... ........... _.........-.--.-----....-,.....---.._..I....................... r� P Address . ..-... � ........ City ............ ._.. .. ..................................... l T ; --------- --- --- Contractor's Name ._. �L-+te r.---- _..-.`.........�--- ---.License Phone .......................... .. Installation will serve: Residence [�/Apartrnent House C] Commercial❑Trailer Court Motel ❑Other Number of living units:....-r_._._ Number of bedrooms -.2".._-Garbage Grinder .........:.. Lot Size ....�t�`�! -'' .....-. Water Supply: Public System and name .................Private Character of soil to a depth of 3 feet: Sand 0 , Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay loam ❑ 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,) PACKAGE TREATMENT ( ) SEPTIC TANK f I Size................................................ Liquid Depth ......................... ' Capacity ..............a-.--, Type --•-••-------------- Material...................... No. Compartments ...............•----r + Distance to nearest: Well. _...................................Foundation ...................... Prop. Line .....................09 I LEACHING LINE [ j No, of Lines ........................ Length of each line-----------._...__.......... Total Length _-_.__..._................ - r . 'D' Box ------------ Type filter Material ....................Depth .Filter Material ............................................ Distance to nearest: Well ........................ Foundation .._...... ............. Property Line ........................ SEEPAGE PIT [ J Depth ........ ........... Diameter ................ Number -------------------......... Rock Filled Yes ❑ No (3 . Water Table Depth .................................,._............Rock Size ................................ Distance to nearest: Welf ...................---------------------Foundation .................... Prop. line .....................V REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------- Date ..........__..............,......-) V Septic Tank (Specify Requirements) --•-•---•-•---• ---- ..----•-......... ---------------••--- ----------- ................................................ Disposal Fieldr (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 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 Work n Compensation laws of California." Signed ------------------------------ . ......... ---•• . . --- --- _ ....... ------------- Owner (j� BY ---- --- • ............ ... ----- Title_... 7 tle - ....--- ------.....-----..._... ....... . ..... Of other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _.__ .. . -----------------•---------------------------- --------- --- DATE BUILDINGPERMIT ISSUED --- ---------------------•----•--- --------------------..........------------------...................---DATE - ------ --------------------- •-- ADDITIONAL COMMENTS ----------- ------- ------------•------•--.-..---------••---.--••_...._.... ............................. .-- •---•----•-•------ inaInspection by. r-- ----- -----------•--.......------....----....---.._............- ..----....Date ....._...... •.............. EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71t 3M f