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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate? Permit No. ............y...... -- This Permit Expires 1 Year From Date Issued 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: J� c'C T`. JOB ADDRESS/LOCATION .�. - s------- ------- ...........CENSUS TRACT Owner's Name ev le ( t e tspN............. . Phone `{�,� `I Address ... City _ ? ...... ...._... Contractor's Name f�• �Ft��(SwEnis :.............. =................. �nt c :....................... ..License # ' Phone -. ?6: ��.: Installation will serve: Residence (Apartment House❑ Commercial oTraller Court ]] Motel ❑Other......... ........ ....................... Number of living units:__.------- Number of Brooms . .. .-..._Garbo a Grinder __....:_.__. lot Size ..:��_�-.��_ :•-_-•__ g a i Water Supply: Public System and name'.. __..._ .............Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat[] Saridy Loam ❑ Clay Loam ❑ . _.. . Hardpan E] Adobe 'n 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 septic tank or seepage pit permitted if public sewer is available within 2.00 feet,J r PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size.................._�._.y__.................... Liquid Depth ..........................'-----.. . t t ......._ Capacity -------------------- Type .....___--------:.- Material-----................. No. Compartments Distance to nearest: Well -------------------------- Foundation --__--_............. Prop. Line 1 ........... J LEACHING LINE [ ] No. of Lines --------- -------------- Length of each line......................... _.. • ..............: Total Length - :......_;.. V-' 'D' Box ------...:._ Type Filter Material .Depth Filter Material .......................... ..... ' Distance to nearest! Well ....... Foundation .....__._ .... Property Line . SEEPAGE PIT [ ] Depth -_.•---------------� Diameter -__....---....-_ Number ---- ...__.----•- --.__ hock Filled Yes 0 No � 1 F Water Table Depth t ` ...........................................Rock Size Distance to nearest: Well ...........:............................Foundation ..................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# _...___..__......._----------•--•--...------ Date ....:# ........................ Septic •---- ) s Tank (Specify Requirements) ..__......-•--..�.......... ................................ Disposal Field (Specify Requirements) ......... ........................................ .. S' �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 Sail Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District, Home owner or Iicen• 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 svch manner as to become subject to Workman's Compensation laws of California." t Signed -------- ------ - - ................... Owner By ............... Title ..�. . _�...... (If other than owner) a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE ..---•• -- ------ _5 • , ..- BUILDING PERMIT ISSUED.... . ..................... DATE ...........------. . ,,, .._I......-•-•-----•..---..._......---•..........I.......... ADDITIONAL COMMENTS......... - .,...... : ......................................................... ................... .... ...._......-•-•-•...............•--•---.......-••----•--......------.....-------•--•----•-- 3 Final Inspection by -.... J ..........--••--•........._Date ......... ...... {{_�. ...... m SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 24.1.'68 Rev. 5M 7 u