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POR OFFICE USE: APPLICATION. FOR SANITATION PERMIT c� Permit No. ..�:�... (Complete In Triplicate) — 7J/ ..............................I.._. ... _ ..- mate is:ued`..�.�-..: ... This Permit Expires 1 Year From Date Issued r -- - 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 Rules and Regulations: JOB ADDRESS/LOCATION ....... ...........................................................CENSUS TRACT .................. ...... c,53 Owner's Name ..................:................Phone .. yam. Address .Cil ' " ........................ .............. 4 � Contractor's Name ...............••..License ilt 3.1 .1 11 Phone installation will serve: Residence Pah Apartment House Commercial QTraller Court 0 Motel ❑Other ............ ................................ Number of .living units:-. Number of bedrooms .�t..Garboge Grinder Ae. Lot Size .....gg C . '' �' Water Supply: Public System and name ..................... ........................................................................................Private Character of soil too depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam ❑ Hardpan Q Adobe Q 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 200 feet,)' PACKAGE TREATMENT [ ] SEPTIC TANK I I Size....... 1 �•.-•--..•.......•----•-- Liquid Depth ....................... CapacityType .... Material....................... No. Compartments .......... r Distance 'to nearest: Well ..................................:.f=oundation ...................... Prop. Line ......... LEACHING LINE No. of Lines .. ... -- Length of each line.- -- _Total Length . . •---••--•• a 'D' Bax 4.------- Type Filter Material .1 .......••.Depth Filter Material ...... Foundation --. Property Line e�-0V...... Distance to nearest: Well _..��/-..... �-.......... - P rtY ...••�•� �R TO SEEPAGE PIT Depth -- --------- Diameter ... "'_..._. Number .......-------•............. hock Filled Yes ❑ No Q ► Water Table Depth -• ----------------...........................Rock Size ...... ..................... Distance to nearest: Well .......................-................Foundation .................... Prop. line ...•--.. ............. REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ------------------ --- Date ........................ ------- SepticTank (Specify Requirements) ---- --------------- ......................................--------........-----.........----------.....---...........__........---•------ Disposal Field (Specify Requirements) ---------- ....................................... ----•----------.......-_ ................. i --------------------------------------------------•- --.... . ' - ---- -- --- - • - ------------------. . --- ... ...... •--- -- --- I 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 4 BY -• ----------------- --------------- Title ...............-----'...---- ............................. ------------............. (lf other than owner) R DEPARTMENT USE ONLY _ y APPLICATION ACCEPTED BY _._._ ---------------------- DATE - 1 BUILDING PERMIT ISSUED ----- ----------------•_.----------------------------- ------------DATE ......--_---------•-••------------._... ADDITIONALCOMMENTS ---••------------• -------------------------------------- ._...... --•------------------------------------------ -------------..- • ........ ------------------------------------ -------- ---------•---------- -----------------•--•---------....------- ................---------........................................ . _ i j,._._-.-._-.... --------------------------------- ----------•--•- --..._.-- ------- -- inai inspection t�Y . --- ) 1 13 2L 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M 4 ,�