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, QR OFFICE USE: _.t APPLICATION FOR SANITATION PERMIT ? 1- (Complete in Triplicate) Permit No: ---- ----------•----------- ------------ This Permit Expires 1 Year From Date Issued Date Issued __�.�_- 7-;. •� j' 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 `-- _D_-_--- --_ = � - -------- - ----------CENSUS TRACT Owner's Name ---- - •----- -------Phone.._ . �`'afi Address - '- _ ----------/ ------ _..."City' ------------------------•-•-•------ Contractor's Name ________ P�c��-- ---.License # ----- Phone Installation will serve: Residence)X Apartment House-L-3 Commercial-=BTrailer-Court ;❑ t Motel ❑ Other ---___-- --- - - --------------------------- G Number of living units:_-____ ___ Number of bedrooms -----�-___Garbage Grinder ------------ 'L t S' a -__._ �� d r tf- ------------- Water Supply: Public System and name --------------=- '---------- _ __--____Private ❑ , Character of soil fo.a depth of 3 feet: Sand' Peat Silt.❑ Clay ❑ Peat❑ Sandy Loam ❑ Gay Loam.E] Hardpan ❑ Adobe ❑ 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-. ------ Liquid Depth --------- ----- 4 Capacity -------------------- Type----- —4 ------- Material----------------_ - No. Compartments Distance to nearest: Well -------- --- ------ - Foundation ----------------_,---- Prop. Line ------------------_--- LEACHING LINE [ ) No. of Lines ------------------------ Length of each i ------ Total Length --_- ------ 'D' Box ----- ------ Type Filter Material _____ �-----Depth Filter Material _--------------- ----------------•- Distance to nearest: Well '_- Foundation _.--------- Property Line l t --- SEEPAGE PIT [ ] Depth ---------__________- Diameter __ Number---- Rock Filled Yes [] Na i❑ t=' Water Table Depth -` '--- ---------- -----------------Rock Size ------ i Distance to nearest: Well ----------------------------------------Foundation ---'----------__------------- Prop. Line ----- ................ ` F REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ Date __-____-__--_____ Septic Tank (Specify Requirements) ----------------------- ----- - - - r I------------------ -a - Disposal Field (Specify Requirements) ------ ----- - _ , -r ------- - ,._ • ------- , ----------- -- -- - 3_- �� ----------------------------- �, . :. ....-.--..--.-.-.-.-.-.-.-. ............... --------------------------------------------------- . . q t }! - - - ----------------------- - {Draw existingand re uiredcaddition 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. 3 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 BY -- --- - ----:`Title . (If other an ownerM j RTMENT USE ONLY APPLICATION ACCEPTED BY -�_� _ _ _ BUILDING PERMIT ISSUED _ DATE - / - //---------- ADDITIONAL COMME T s �' ----- - - - -- ---- --------- ----- - -- -------_DATE ------------------------------------- ----- - ---- -- -- --- ------------------------------------------------------------------------------------------------------------------- ---------------------------- -- ---- ----------------------------------- ----------------------------------------------------------------------- = ina Inspection 6y: __.__ _Date JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 '} 1-'6--$ Rev. 5M ,..