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F'OR OFFICE USE: A APPLICATION FOR SANITATION PERMIT 6�7 .........- _�".a.-..... Permit No. .... . ....... (Complete in triplicate) � This Permit Expires f 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 with'County Ordinance No. 649 and existing Rules and Regulations.- JOB ADDRESS/LOCATIION V 1 ......____...........CENSUS TRACT .......................... Owner's Name .... / • •......................... . ...........:.:....Phone ........... .. ............. Address . .......... ............ City ---'-- --------' ---•--- -•------ ----------------•--•-•--•---.-..:.... Contractor's Name .-.. .._-...�/.. ...:/� ---------- h: License # /c+�jI—J7.3 P h a n e .o,, fZ Installation will serve: Residence Apartment House 0 Commercial []Trailer Court ❑ � Motel,,❑Other Number of living units:.../.,... Number of bedrooms ---�" .Garbage Grinder ./T�l'-• lot Size ., eJ.----,0C.._`h�.1'�. ........ Water Supply: Pubiic System and name ....... = - :...Private,[{ Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan•0' Adobe Fili Material ............ If yes, type ..................I.......... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placedf on reverse side.) F NEW IN$TALLATIONe _(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ' Size ........ Liquid Depth �EPTIC-TANK__Pd ty lfj®...... Type'OL ..... Material�/ -..__---- No. Compartments 2-............. , - Pro Line . Distance Nearest: Well .s/.e--.•--- ----.-Foundation ./s�.......... l p. �..............� I LEACHING LINE No. of Lines /. ---- Length of each ?line./Ak;. ......... ...... Total Length /00, ....._......-.-_. -'D' Box Type Filter Material --------Depth Filter Material X �.-..._. . o. .. / i / Ir Distance tnearest: Wel! .... _. ......-- Foundation /.�. ..../............. Property .Lina ...-................. ''� � � �' � ,fes t L� "«,.. .. SEEPAGE PIT De'pt .__-_... Diameter' ....... .Nurr►ber', .� ,Rock,Eiiled, Yes, No {� Water Tahle. Depth,_.:..'. ' ` "- --- -------------............Rock Size .----.---• --- Distance to nearest: Well`..-.- ----------------------Foundation .fly........--. Prop. Line .......-.---_---_--� I REPAIR/ADDITION(Prev. Sanitation Permit# --------- --------------------------------_ Date -.-...--..----------.-------------) Septic Tank (Specify Requirements)•..^`....... ------------------- -------------------- ------------------_................... ............-- -• -•-•-- ` Disposal Field (Specify Require'mentsl •-- ....... ................................. ..............•.......,.. ...........--•...---...... t .. fa- -------------------------- -• ...... .......... ......... - ................. ..... ..... .__....... . .... ----' ------ .......... . .... - -------' .................... .............. ........ . ` (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 licem 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 j as to become subject to Workman's Compensation laws of California." Signed . ............. - ..... . ... .. Owner By --- . .. ........................ ----------- *e • Title . �''�: . . (If owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ...... -- `�/.,:_...... ... DATE .. .. , .. S ......-- BUILDING PERMIT ISSUED'....... ........... ..... _... DATE . ................................ ADDITIONAL COMMENTS -----------------. ........................ {-. - - .. ........._------------------ ---- _ --------- Date Final Inspection by: .. . .... _._----..... _ _ SAN JOAQUIN .LOCAL HEALTH DISTRICT E. H.13 24 1-'68 Rev_ 5M 7172 3•,-M.