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FOR OFFICEUSE: _ice�r APPLICATION FOIe SANITATION PERMIT r - l_--- ------ (Complete in Triplicate) Permit No. . This Permit Expires i Year From Date Issued Date Issued ;f �/ Application is hereby made to the-San Joaquin'Loaai Health District for a ' described. This application is made in compliance ' h County Ordinance No. 549permit oq d existing nRulestalndthe work Regulations.,rein JOB ADDRESS/LOCATION __ __ _ __ _ ; ------------ - ._ -- -Owner's Name -'---'-= ------------------CENSUS TRACT __-_---- --j- - --•-•------ -------- -------- -- -- -- ------=------- Phone � .Address -- -----' - -- - - --- - �-�--- --. City Contractor's Name _.._--'------ ---- -------------------- ► � � - ------- -----------------_---•.-...-- ---- ------_-' License #��/ Phone Installation will serve: Residence P<Apartment House f] Commercial ❑Trailer Court ❑ C Motel ❑Other Number of living units------- ____- Number of bedrooms --Garbage Grinder -:---------- Lot Size F TY t Water Supply, Public System and name ------------ r -'--�-4�**----Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ . Clay ❑ Peat 0 Sandy Loom ❑ Clay loam Hardpan ❑ Adobe 0, Fill Material - _--------_ if yes, type __tr (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 i_f public sewer is available within 200 feet,) PACKAGE TREATMENT { ] SEPTIC TANK:[ Size , J i ---- Liquid Depth Capacity _ -TYpe ----- g Material---------------------- No. Compartments ---------------- Distance FI =----pd to nearest: Well ----------------------------- ------Foundation ------ --------------- Prop, Line ---,------_-------•--- LEACHING LINE [ ) No. of Lines ky3 Ln -------------- Length of each 'line---.----------- .�` ----- Total Length D' Box ------------ Type Filter Material ------------- -----Depth Filter Material - _ _ -_._ --------------------------------- Distance to nearest:WellA_'-"__--___-----_---- Foundation ------------------------ Property Line ------------------•-----� SEEPAGE PIT, � � [ l Depth -------------------- Diameter - Number ---------------------------- Rock Filled Yes ❑ No .0 --------------- Water Table Depth "' I t -------------------------- ---------------------- Size Dist - i ---=-----Foundation --------- -------- Prop. Line .--------••--------•-- REPAIR/ADDITION(PrFance to nearest: Well ----------------------------ev. Sanitation Permit# _----_-_ __ - �. _.. .. ------------------------------- Date ) Septic Tank Tank (Specify Requirements) -------------------. ----------- --- Disposal Field (Specify Requirements)��' -- - -- - - - _-_____________ �� -- ------------- ---- -- ------ ------- - -------------- ------------ e� ------- -------------------- X --------------------- - - {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 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 an ; as to become subject to Workman's Compensation laws of California." p Y Y Person in such manner ,, 0 Signed -- ------ ------- - ----- --- Owner BY --- - ----- ) Title __.. --------- -- -A- ------------------- th owner .--- OR RTMENT USE ONLY APPLICATION ACCEPTED BY ------ ---.- BUILDING PERMIT ISSUED ------- ---- - ------ --- DATE ----- BUILDING --------• --------- -'------- -- DATE ----------- ------------- ADDITIONAL COM NTS _---- - ---- ---- - ---- --- ------- ------------------------- ---- ---- -----------------------------------------------=----------------------------------------------- Final Inspection by: -------------------------------------------------- - - -- --- -------------------------------- --------- -- -- - -------- -------.Date N OAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Re V!