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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...____---------------- {Complete in Triplicate) Permit No. ---- ---------------- `�!�_ ---- `.� _2 � 3 -- - - - �------ This Permit Expires 1 Year From Date issued Date Issued _.,___.-f!/C'_._- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install e work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS LOCATIO 4 1 �L.C�.` �. - -- -- - -- --CENSUS TRACT ..: _ .'.... Owner's Name n ---------- Y Address ' r Phone - _. City -� z. ------------ Contractor's Name - Z ----- License # � - �— -- � --- - - Phone --- ------- Installation will serve; ----------- Residence%Apartment House❑ Commercial ❑Trailer Court i❑ Motel ❑Other . -_-- _--_-............................... Number of living units: - - -._-- Number of bedrooms _-< .._.-Garbage Grinder Lot Size Water Supply, Public System and name -------------------------------------- -- ------- ---------. -------------------------------------------------------------Private [� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam� Clay Loam E]Hardpan ❑ Adobe ElFill Material ---------- If yes, type -------- ------- ----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: fNo septic tank or p'seepage a e rt 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 ----- - SEEPAGE PIT ) Depth -- --- ------- ---- Diameter -,-------------- Number ---------- --- P -- roperty Line --------------------•-- ---- Rock Filled Yes CJ No 0Water Table Depth - ----------- .............................Rock Size ------- ---- - Distance to nearest: Well ---------------------- ------- ----- -Foundation -------Pro-p. Line ------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------- -- -- --- - -- ------ Date ------- �----- - - ----1 --- Septic Tank (Specify Requirements) -------- ----- ---- - ---------------- -------------- ----- Disposal Field (Specify Requirements) a- = - ------ - ---,-1-- '- -- ------- --� �'--'�.'___ --- --- -- ------------------------------------ raw exisfiing"and re uired a dition on Y/ side) I hereby certify that 1 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 Son Joaquin Local Health District. Home owner or licen- 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 as to become subject to Workman's-Compensation laws of California." Signed -- ----- ---- ----- - - y ------ --------- Owner (If other than owner) ! Tifle - ------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - v ; BUILDING PERMIT ISSUED ------ ------ --------------------- ---------------- DATE . �- -� -- ------- ----- ------------------ ----------------------------- -- -- TIONAL COMMENTS -- - --- - - ------------------------------------------ - -- --- = -•- ------ DATE -- ---- - --- ----------------------- ------------------------ ------ ----- ----- ------------- ----- - -- - - ------ -- .---- ----------------------------------------- Fina) Ins --, ----- -- Date -------- -------- SAN JOAQUIN LOCAL HEALTH DISTRICT A11 E. H. 9 1-'68 Rev. 5M