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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i Permit No. (Complete in Triplicate) ............ ........ ......... •---- .............. (, „_,,,,,,,,;• .- ::`-----..-.- This Permit Expires 1 Year From Date Issued Date Issued 3 a S T 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 Ryles and Regulations: i JOi3"ADDRESS/LOCATION A a r._ rs. .��,............................................CENSUS TRACT .... ....... ; Owner's Namei � 1 ................................................................ ..... ......�.......Phone ......... .......................---- Address � ....--••--•---••7 - .. Cifi Contractor's Name .... ° ..................................................License # v��1, ... Phone ---------------•-----... - Installation will serve: Residence &Xpartment House Commercial ❑Trailer Court Motel ❑Other ....................... .................... 11 Number of living- units: -��_ IJumber of droom ....Garbage Grinder#. - �. Lot Size .��rJ.,e ...,/. R Water Supply: Public System and name .. ..�� ll�- -�iV_ -�....tt'` ----- -----------.................•........._......Private ❑ Character of soil to a depth of 3 feet: Sand7] Silt❑ Clay ❑ Peat❑ Sandy Loom ❑` Clay Loam ❑ ' Hardpan ❑ Adobe ill Material./LJ2?. if yes,type ............................ v` (Plot plan, showing size of-lot, location of. system in relatlon 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 ............... ...... ----_- Len th of each' )lite.___:__•.:.............. Length ..._.........._. LEACHING LINE ' [ ] No. of Lines--.-.___________ __ g ___: Total Len ....._......� 'D' Box ........:... Type Filter Material ....................Depth Filter Material ---.--- .................................. Distance to nearest: Well ........................ Foundation ........................ Property Line .................... SEEPAGE PIT Depth .................... Diameter ........... Number Number ._.....______....... ....... Rock Filled Yes ❑ No t] Water Table Depth ....................Rock-Size r' Distance to nearest: Well .........................._.......•......Foundation ------_---- ...... Prop. Line _... .......... ' REPAIR/ADDITION(Prev. Sanitation Permit# ..............................: : .._.._.. Dare _.........•---------•-------------- Septic ----------- -Septic Tank (Specify Requirements) ................ ............. ----•------------------ —................. Disposal Field .(Specify ,Require ents)----------------- _.__. ._Q�._. ..-- -•--- �..------•----------- ---------- d --- u ...---------------------------------•-------------•-• --- ----------------- ---- ---•-.--------•--------- _(Draw existingand required ired 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 any person in such manner l as to become subject to Workman's Compensation laws of California." Signed ...........................• •- ...:.... ..... ... ............................... Owner By .. - Title_._ .......... ------•----- .... .......... .....•. (If oth tan owne ( FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . ----:=•� .............. .. ..., BUILDING PERMIT ISSUED .4..............*................7DATE ....3 : ..,.... .......DATE ADDITIONAL COMMENTS --------------------------- --------•------••----... ................................... -•-•---------- -------•--------------............................_.:_... ---...._...._............--••- --- -------- - ---.--------- . . .............................................. ....................I....................... _ Final Inspection by: .--------- 1�-- -••- ......-'� � _. . ... _Date _. �- .�.Z. ................. SAN JOAQUIN "LOCAL HEALTH DISTRICT f �_ H 13 24 1_'AR Rpm_ 5M -7/72 3 14