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FOR OFFICE USE: u. APPLICATION FOR SANITATION PERMIT {Complete in Triplicate} Permit No. -------------------------------------_--------------- This permit Expires i 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 wit County Ordinance No. 549 and a isting Rules and Reguldtions: JOB ADDRESS/LOCATION40S ------------- ------- ---------- CENSUS TRACT -.1--------- s Owner's Name --. - F -------------Phone --------------------••9� j Address ? . ------ I -- --------- - --- ---- City -------------------------------------- •-------- Contractor's Name --------- -- -- --------- - License # -� � Phone ----------------------------- Installation will serve: Residence A artment House❑ Commercial ❑Trailer Court ,❑ r Motel []Other --- -- ------------------------------ Number of living units:---__ __._ Number of bedrooms _ ___'.Garbage Grind -er--___-�Lot Size _____________________ 1 = Water Supply: Public System and name ---------------------- --------------------------------------------------------------------------------I--------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat[] Sandy Loam ❑ Clay Loam i l Hardpan ❑ Adobe '❑- Fill Material ------- If yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells,Rbuildings, etc. must be placed on reverse side.) NEW INSTALLATION: fNo septicitank or seep a pit permitted if public sewer is available within 200 feet,) 4 PACKAGE TREATMENT [ ] SEPTIC TANK'[ —Sixe_T gg �l-7 �------------- Liquid Depth ----- -------------- Capacity:1.a-00- ype Material-i ----- No. Compartments ------ istance to near st: Well __ ._._ a___________________Foundation ___/_4__________ Prop. Line _ .__.._'_ LEACHING LINE { o. of Lin s ______. �______.__ Length of each fine- ---ea.E___.______ Total Length ,____� 5-------------- 'D' --- 'D' Box __ Type Filter Material __cl_� ___Depth Filter Material ----------------------------- ' t Distance to nearest; Well _____�r'__d__f_______ Foundation ------l._0.--- -_ Property line __1�_—___.._____________ SEEPAGE PIT [ ] Depth ---- --------------- Diameter ---------------- Number ------..-------------------- Rock Filled Yes '❑ No 0 WaterTable Depth ---------------------------------------=--------Rock Size ---------------------•------•--- : Distance to nearest: Well --------------------------------------- Foundation --------- -- ------ Prop. Line .---------------`='--- REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------_-------------------------- Date -----------------___________} x ; Septic Tank (Specify Requirements) ---- --- --------- --------- �._ - -- ------------------------- -- - - I" Disposal Field (Specify Requirements) ___ ------ =;2-- 1 4 ______ _ _ ______r ---------------------____....______________ _____--_______________---_____________________________________.__.____.__-_.____-._______________ ------------------------ -- ___________-___________ ______________________________________________ w __________ _________________________________________________ (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 Mules and Regulations of the. San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify tha ' the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom s biect to Workman's pensation laws of California." e Signed ---- ------------------ ------ ------------------------------------ Owner By s t` Title --- ---t-------- ------------------------------------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------ ------------- DATE/O-/ --------—----------------- I BUILDING PERMIT ISSUED T -- ---------------------------DATE ------------- ------ •------------------- ADDITIONAL COMMENTS -------------i-------------------- . - ------ ------- - __-------------------------------------- - ----------- _o. --- � --- -- _ - DaFinal Ins ectiby: -- - --------- --t - --- 7--- - --- - - F SAN 'JOAQUIN LOCAL HEALTH DISTRICT J. E. H. 9 1-'68 Rev. 5M 7. �