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FOR OFFICE USE: .............................................. APPLICATION FOR SANITATION PERMIT .................................. Ice Triplicate) Permit No. . This Pit expires Date Issued ....................................... ermres t Year from Data 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 ounty Ordinance No. 549 and existing Rules and Regulations: f .l0$ ADDRESS/LOCATION f��•- o .. --------....CENSUS 'TRACT Owner's Name ..�_f .11� _/ $®_��',............................. ... - ...... Address / _ C�..T ,..... Phone X3`.. , ,1._.._ .-- --- .-.-.-City !!t�l� _ -----• --•--..... p� Contractor's Name .__4 .License # � _ Phone 4� .~b i Installation will serve: Residence Apartment House Commercial❑Trailer Court 0 Motel C]Other....... ...._ i Number of living units:.....(----- Number of bedrooms .,2.-..-Garbage Grinder ... ..- Lot Size Public System and name ••- Water Supply: .......Private Or Character of soil to a depth of 3 feet: Sand R Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam❑ � Hardpan❑ Adobe 0 Fill Material ............ if yes, i (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 publlC sewer is available within 200 feet,] PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................. ... ----------------- ........ Liquid Liquid Depth .......................... Capacity ..-• -------••--•--- Type . •-••--•-••..... Mater I---------• --•-• --.. No. Compartments p Distance to nearest: Well __....__.___ ..Founda on p, . -•---.....-•---.. .... •-•------------------- Pro Line ........-------------• � LEACHING LINE [ j No. of Lines Length of ea line....... Total Length 'D' Box Type Filter Material ..__.De th Filter Material Distance to nearest: Well ................. .. ... Foundati n ......_ Property Line { SEEPAGE IT ( Depth -------------------- Diameter Num r Rock Filled Yes ❑ No ❑ ........---•.............. Water Table Depth ------------------ .__.Rock Size ff 1 Distance to nearest: Well ......._. _. ..Foundation Prop. line ----•--•----....... ....--•---•........ REPAIR/ADDITION(Prev. Sanitation Permit* -••••••---- •--• --•-•••. ------ Date --..------- Septic Tank (Specify Requirements) .. .............. -• Dis osal Field ecif i ( p Y Requirements] . • ........ _.. ------------- ! . / k -------••------•- -•-------------------- (Draw existing and required addition on reverse side) ' I hereby certify that I have prepared this application and that the work will be dons in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local HOW&District. Hants owner or Ilcen. sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to Workman's Cam ensation laws of California." Signed -,--------- Owner j, BY 1 r.-.._ - Title -------- ---- (lf other than owner) J --�-----•-'-••••---.----------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... - . -- ----- ---••-------- ....------ DATE 87i;'7s-- BUILDING PERMIT ISSUED ... --•• ---• - _--- _-•-• - ._ ._ _ --------- -•-- -- ..----•- ..DATE ......... ..........•------- ADDITIONAL COMMENTS .......... .........•------ .....------- I----------------- ----------------------------------------------- -----...........-........ ----------------------- --------------.....---••••• -.... _ Final Ins -------------------------------------------- --- -----...-----------•--------------•------•--•-------------------.-..._----------- ------------------ -- Inspection b _ P Y � ... ....I...............-------- --------- ..............:...Date ....---- ."Q�` -'? `.-- EH 13 24 1-•68 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M �