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-FOR OFFICE USE APPLICATION FOR SANITATION PERMIT ..� No Permit . .I/ x 4Complete in Triplicate) .... .. . Date issued This Permit Expires I Year From Date Issued 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 pxqpliance with County Ordinance No. 549 and existing Rules and Regulations:. JOB ADDRESS/LOC ION !� CENSUS TRACT f. .--- .............. ........................ Owner's Name -- --- -- - - ----------------------------------•-----...........................................Phone ....................-............... Address -._ ........ City Contractor's Name -7 i;. . z .......----••----..License , ./. . Phone .:, 1......7. i� Installation will serve: Residence Apartment House Commercial❑Trailer Court Motel ❑Other............................................ \ Number of living units:..._/__.... Number of bedrooms ..A....Garbage Grinder ............ Lot Slze ...�.�_t�_.�...�L`'......-_. Water Supply: Public System and name ............... ..•--••----•......._.....-...................................................................Private Q Character.of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat.❑ Sandy Loam f] Clay Loom k Hardpan ❑ Adobe t3 Fill Material ............ if yes,type ... ....... ............ l (Plot plan, showing size of lot, location of system in relation tarwells, buildings, etc, must be placed an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) PACKAGE TREATMENT f ] SEPTIC TANK{ ] Size.._ _ ... ~. - Liquid Depth '4-/.. ........... Capacity --`_ Type ... Material... No. Compartments Distance.to nearest: Well ____ ......... ...__._. LEACHING LINE [ ] No. of Lines ..__.. ----._.--.- Length of each line....... .....:........ Total Length ... ............. 'D' Box . .. Type Filter Material ..../-.. ..Depth Filter Material I Distance to nearest: Well .................. -..... Foundation Property Line ........................ SEEPAGE PIT ( I Depth Diameter Number .............................. Rock Filled Yes ❑ No ❑ Water Table Depth ......................... .._------------•-_--Rock Size ....._........--••.._. ......... Distance to nearest: Well .....Foundation ....... Prop. Line .REPAIR/ADDITIONIPrev. Sanitation Permit# ............................................ Date __--•---....... ............... SepticTank (Specify Requirements) .-•----•---------•-----••..........................•• ......... ............................................-............................ Disposal Field (Specify .Requirementsl -----------------•---------------- -•••.._ ................................... .................................I——.......... ---------------------------------------------- ------------ ---------------------•--• ------ ------- .................................................................. _.. (Draw existing and required addition on reverse 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 San Joaquin Local Health-,District. Homo owner or lice". sed agents signature certifies the following.- "I ollowing:"I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------"-.- ............_ . ----•- Owner By ---------- --------- - --- -----•------ --- -------------_ ------ Title r (if other than owner) FO"EPARTMENT USE ONLY ' APPLICATION ACCEPTED BY __- ------------------------------ DATE ..- BUILDING PERMIT ISSUED - --- ------------------------------:------- .......DATE ...... ----------------- --- ADi]fT10NA1 COMME S .................. ........ t.. _.. ..----- ------- .._._.. ..... •--------- -• ---•----------------------- ---------------- - --- � '+ Final Inspection b ................. f p Y° - ....................Date . EH 13 24 1-6i; V. � �.. ... .. ......... .. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M k