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'FOR OFFICE USE: " • APPLICATION FOR SANITATION PERMIT t ------------ i CdipleteirsTripl€fate) Perm--------- i "-- -------------------------- -------- 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 described. This application is made in compliance with County Ordinan a No 549 and existing Rules and Regulations: " herein > �. JOB ADDRESS/LOCAT ON'._ _141V 1' j �� - ------------- ----- -------------- Owner's Name '----CENSUS TRACT -------------- -------- --_-_" � ��b_ .. 4 -------Phone ----- -------------- Address ---� - --••-•-------•- ,�--------------- ------ ----------------- �--------- City -- Contractor's Name -- -------------- =.---------------------------- -------------- ------ -----------•------- --- ----- -- - - --- -----------.License # ------------------------ Phone.---t Installation will serve: a ___ Residence 'Apartment House,[D Commercial OTrailer Court ;❑ { Motel C1 Other Number of living units:-.--'/---- Number of'bedoo s _ __Garbage Grinder _-- ----- Lot Size a PpY: Water Supply. Public System and name ----- -----------------•-------•-------- _Private ❑ ---------------------- - aracter of soil to a depth of 3 feet: Sand'❑ Silt❑ Cl Y EDPeat E] Sandy Loam -E] Clay Loom.[j Hardpan ❑ Adobe�Fill Material ------------ If yes, t {Plot plan, showing size of lot, location of system;in relation 'to-wells, buildings; 'etc:'rriust be picked on reverse side.) \ NEW INSTALLATION: {No septic tank or see a e t permitted if public sewer is a�ailable within 200 feet,} `� P g Pi PACKAGE TREATMENT [ ] SEPTIC TAN y y Size--. ,�1 r� �1 ------� ------- Liquid Depth ------ Capacity/2'0-0 -_ \ -------- (� -_-,--- TYpq� P 4 aterial-PO PI C No. Compartments --------- r - ^� Distance to nearest: Wel _ �`�`S .40 `------�.�--- ----- Foundation ---�2--------- Prop. Line ----- z \� LEACHING LINE [ No. of Lines / � -------------i Length of ch Ii e----- ---------------------- Total Length ' 'D' .Box ______----_,°Type Filter Material /i Depth Filter Material ___ _ _ _ - ___ •---•---- Distance to nearest: Wel! ��'•*✓ � `•---'-� ` Sit?_____ Foundation __.----- Property ine �[ SEEPAGE PIT L 1 Depth --------- -------- Diameter ------------ Number --------------------------- Rock Filled Yes No 0 As Water Table Depth ----------------- ------ ------------- Rock Size --- -------- ---------- , Distance to nearest; Well ----i REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ -------------------- Prop.'i.ine --------•-------- { _.____-•-_�-__---_--_ - --------------------- Date Septic Tank (Specify Requirements)' Disposal Field (Specify Requirements) ___---_____ - _ _ _ --------------------- - ----------------- --`-- 4 11 =-------- -- - - ---- ------------------------------------------------------------------------------------------------------ (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._ . "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 bet subject to Workman's Compensation laws of California." Signed -.-- --- ------ - By - --- - - ------------------- Owner { other than owner) -------------- Title -------- - ---------------------- - OR ARTMENT USE ONLY APPLICATION ACCEPTED BY - BUILDING PERMIT ISSUED "� _--DDITION L NOMMEN S DA ----- ` `..r ♦� S��- ---- ----- ----- - ------------- -------- i al inspection b f �' - 4 f �_ _fL ------------------------------ -- --------- Y------ --------------- ---Date " JOf ?IN LOCAL L HEALTH DISTRICT E. H. 9 1- 68 Rev. 5M /Q'