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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ',,............._.... .......... . . ............ Permit No, .. (Complete in Triplicate) ............. .............. 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 herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ...... .... ....... ..........................•............CENSUS TRACT Owner's Name ....... ...... •-- ......... ... ........... ............................................... hone ..... ... ... _ ........ FAddress City . ..............c....�'.� y Contractor's Name .................. ...... ..... ....... ... . !..................License # 253..0.J .A. Phone Installation will serve: Residence❑Apartment House 0 Commercial❑Trailer Court 0 y Motel ❑Other ............................................ Number of living units:.... ..... Number of bedrooms .__ �.....Garbage Grinder . .... t Size ..Oke z k. ................. Water Supply: Public System and name ........................................ . Private ❑ Character of soil to a depth of-3 feet: Sand❑ `_ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 0 Fill Mcterial ............ If yes,type............................ (Plot pian, showing size of-lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No s ptic tank or seepgoe pit permitted-if public,sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK ] Size................................................ Liquid Depth .......................... Capacity .................... Type .................... Material...................... No. Compartments ...................... Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE [ ] No. of lines ...... Length of each line............................ Total Length ............................ 'D' Box ............ Type Filter Material .....................Depth Filter Material Distance to nearest: Well ............. Foundation .........I............... Property Line / SEEPAGE PIT [ I Depth ........ Diameter ............... Number ........................."R&JCFilied Yes Q No 0 Water Table Depth Rock Size ................................ Distance to nearest: Well ...............................:........Foundation .................... Prop. Line ...................... ao, REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date....................`_:........... ] i Septic Tank (Specify Requirements) ......................... _._._...._._.....................w......................_.............................. Disposal Field (Specify Requirement . ....y� ( ..... - _ - •-•------•--•--••---•-••-----•.......••................ .............................................................. ... •_. X. -a...--- ..... ... .................................I........................ ...............................................•----••-•--••••-........................••-•-- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be don* in accordance with San Joaquin County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lic*n- sed agents signature certifies the following: "I certify that in the performance of the work for which tWs_ptrmit is issued, I shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed ............. .......... .. ..... . . .. ......_........... . Owner, ............ Title By .............. .. • , ..................... . ........... ( t a owner) F_Qr R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ... ...... 7- ...�.,,! ,..:. .. .....:.`DATE ._ J Z,/�..�?, BUILDING PERMIT ISSUED . .. ......_.. .................................................. .DATE.................. ...................... ADDITIONAL COMMENTS ..... .................... ......... pe Final Ins.-_•..ion by: .....- ,.,. . ; � ..... Date .j ,l, . `2 SAN JOA+QUIN LOCAL HEALTH DISTRICT �?� ----� E. H.13 241='b8 Rev. 5M y. :°:r N., 7/72 3 M