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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ...................... .. . (Complete in Triplicate) Permit No. ........... ......... ... ................ This Permit Expires f Year From Date Issued Date Issued ./. -3 S 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 de in compliance with County Ordinance No. 549 and existing Rules and Regulations,- JOB egulations:JOB ADDRESS/LOCATIONZd _. .... .........CENSUS TRACT Owner's Name .. ...... ............. one ...................... -• t...: :.. Ph 10) Address ...._.. City e2� -- . ........ .. --- ............................................. Contractor's Name ..- . . . ..... � -r... ---------------------License # ��1�. phone ...:.......................... Installation will serve: Residence Apartment Hovse❑ Commercial oTrailer Court 0 Motel ❑Other ............... ..:..... ................... Number of living units-1........ Number of bedrooms _--,3....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 ❑ Hardpan irl", Adobe Fill 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: (No tank or see go pit permitted if public sewer is available within 200 feet,j PACKAGE TREATMENT SEPTIC TANKf . Size...Y. '.X_ t x-_- .............. Liquid Depth .. ...._...._ -------•--- Capacity'JA.."-JA4 Type ..... Material. No. Compartments A.-.--............... Distance to nearest: Well .... A.'._ ..Foundation .EV..�_--- .................. .-...... Prop. Line ............. � LEACHING LINE [ No. of Lines .......is.......... Length of each line----- .�?.r.......�' Total Length ..1 a-.�.............. 00 'D' Box ...:�.----- Type Filter Material .....;.!g Filter,Material ...../l.................................. N Distance'to nearests Well ..xsf?.�.............. Foundation --...L.a..I.......... Property Line —407..r.---..._._..Z N - SEEPAGE PIT [ } Depth ..:. ..� --__-- Diameter •... ..... Number ........ .............. Rock Filled Yes No . _ `. Water Table 15apth ...........................Rock Size .._1.. ...... Distance to nearest Well ............... .A_�.e.............Foundation Prop. Lina .................... REPAIR/ADDITION(Prev. Sanitation'Permit# .. Date Septic Tank (Specify Requirements) ~ ' j Disposal Field (Specify Requirements}, ------------- ------ :. ...... , ......................................... . ------------- ::..:. - ----'-------- --- - ........ (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 any person in such manner as to become subject to Workman's Compensation laws of California." Signed ............................................. . Owner By .. �d! +�.- --.... Title .................•-- ....... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ........ ...:. .-•--•---------••-----------•--•---- ---••• . ................... DATE ....,� .. ..7.. ............ BUILDING PERMIT ISSUED ., .-............................................DATE ........................................... ADDITIONAL COMMENTS .................................................... ..._ ._.. ....... ............................................................................................:..... ........ .......... ................... .......... ..... ......:. .............................•--........... .......Date �� Final Inspection by: ................. - 2 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241,'68 Rev. 5M 7 79 1 M