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FOR OFFICE tt E. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No ..�. .. __-• This Permit Expires ? Year From Date lss.ued 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 compliance with Cou Or inance No. 5.49 and existing Rules and•Regulations: I JOB ADDRESSAOCATION ._ ..........CENSUS TRACT Owner's Name P e Address ..� ----- . ...............��.... Ci GG..pp.��.... l Contractor's Name .. ...... _.__ ....;License #Ds�� ....... Phone Installation will Serve: Resid ce l Apartment House❑ Commercial❑Trailer Court 0 F Motel ❑Other............................................. l Number of living units_____________ Number of�edrqo�ms,� _._..,.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 Loa Hardpan ❑ Adobe 0 [Fill Material ............ If yes,type............... ............ - a (Plot plan, showing size of tot, iocati on!af 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 208 feet,) _ PACKAGE TREATMENT ( j SEPTIC TANK N Size__.!,�J.-s-:Ira'i___. Liquid Depth ... . . ........_. Capacity/D-,& Type/k�.'_G terial.�� Nod. Compartments _ - pP -------------------- Distance.to nest: Well .......... .... . Foundation . ..d.. Prop. Line 17.. .. . i .... - r.. ........� LEACHING LINE ] No. of lines ________________________ Length of ea =1me___ Total Length :.ZZJ ........._... 'D' Boz . Type Filter Material .._ Depth Filter Material ._.. . . S Distance to nearest: Well . d _f.__.�i Foundation .:............... Property Line ......... S Deptb:: l.._.____ Diameter Number ... _..._/...... Rock Filled Ye No x � X �z i Water Table Depth ---- --------------------------••--•--•----•-.Rock Size ................ ............... Distance to nearest: Well ........................................Foundation ................! Prop. Line ....:.................Z REPAIR/ADDITION jPrev. Sanitation Permit# --------- ----- y^�...----- ---. Dat ,If F Septic Tank (Specify Requirements ....... . .. Disposal Field (Specify Requirements) ....... - ------ --W- f .. i ------ ---- --------R!--------- ---------------� . • :. ...... ( -------------------------------------------------------- (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 tha ' the perform ce of toe work for which this permit is Issued, I shall not employ any person In such manner k as to becomes jest to W r 'man�dfionlaws of California." Signed _._ ----- Owner By -------------------------------------- ---_ Title -------- (If other than owner) f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ :. l� L . DATE..,..,-.. BUILDING PERMIT ISSUED _ --- DATE ...... iADDITIONAL COMMENTS ---------------------------------•---.------------------------------------------------------------ .----------------•-- ------------------------------------------------------- / Final inspection by: - -•-----•-------- ----------- ...................._-Dote . " � 13 2!t ].—E�£3 Rev. � SAN JOAQUI LOCAL HEALTH DISTRICT 8/74 3M