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FOR OFFICE USE: , 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 fora 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 ----...... ` f ------- ---- CENSUS TRACT Owner's Name -_ <`_ /� '= Phone Address t' >r lf`z��: - ------ ----- ------------ city f Tell.,1_ .� r' .' Contractor's Names f-- �t - -.License # _f_..-2- ----- Phone Installation will serve: l Residencepg"Apartment House❑ Commercial ❑Trailer.Court Motel ❑Other --- --- --.- Number of living units:___ _- Number of bedrooms_- ----Garbage Grinder ------- Lot Size .lee..'X__l_/_ 7a_ 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 Fill Material -__� If yes,type ------------------------- (Plot --- --------(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 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 - ------- - -- __ Property Line SEEPAGE PIT [ ] Depth -- -- .--___ Diameter - Number ------ Rock Filled Yes ❑ No 0 Water Table Depth .. ------- -------- - -- ----Rock Size ---------- ----- --------- Distance to nearest: Well --- __ ______----------.---------------Foundation ------ Prop. Line -.-------------------- REPAIR/ADDITION .____-_-_ -_REPAIR/ADDITION(Prev. Sanitation Permit# ---_--- _ -- Date ----------- -- - --_----- -- -- Septic Tank (Specify Requirements) -------------------., - - Disposal Field (Specify Requirements) _Q: �r _ t_;_ Gc L P ,,..- frl l-,c- � ------ -------- ------------- - i - -- ------- -- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be clone in accordance w4h Sacs Jaagrrin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heallh Wstrict. Home owner or I'cnn9 sed agents signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not ernpioy any person such manner as to become subject to Workman's Compensation laws of California," Signed - - -- -- -- ---- - --- Owner By a /r[1��illt ' �} �, _ JCG', r Title -� (If other than owner) FOR DEPARTMENT USE ONLY y �— APPLICATION ACCENTED BY -- --- ------- - DATF . BUILDING PERMIT ISSUED --.-- _ -- _-- -.----DATE -- ---- ----------- ADDITIONAL COMMENTS C` -- C� � .. VIAL/ ----- ----------------------- _- Final Inspection by: ._ i -- - - -- - ----- - --- - ]ate _ ; ` SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M