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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT M ' (Complete in Triplicate) PermitTlo: _._U.--aS 1 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 made, in compliance with County Ordinance No. 549 and existing Rules and Regulations: - JOB ADDRESS/LOCATI N :-- � _ len- „ ----CENSUS TRACT ----------------__________ a Owner's Name ---------------------- -- ------------- Phone�� --- 4f 77... - , ry y Address ---- � c�Y.f ------ --. City Contractor's Name License Phone _ t- - --� � Installation will serve: Residence)(Apartment House[] Commercial :❑Trailer Court ;❑ Motel ❑ Other -------------------------------------------- Number of living units:----/ ----- Number of bedrooms .,_______Garbage Grinder ___________ Lot Size Water Supply: Public System and n;me ---------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay El Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ Aclobe)<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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_______________________________17___- Liquid Depth ______________.___,_____ Capacity f Type Material NaCompartments , Distance to' nearest: Well ----------- ________________________Foundation' --' ------------ Prop. Line -___--____ r........ \ LEACHING LINE [ ] No. of Lines ----- ----------------- Length of each line-----le -----_- Total Length ____ ...._.._..____ v D' Box _ ----- Type Filter Material A1VeX !"__Depth FilterI _____ t Material ---------___________ sa —/ Distance to nearest: Well __/��?�_�_-_ Foundation ��'_P ________ _-__-__-- Property Line, .___ __.___ eP n t SEEPAGE PIT Depth Diameter .3�---__ Number --- Rock Filled Yes No i❑ [ ] P y- Water Table Depth / Rock Size .K-'2--••------ f Distance to nearest: Well ___-_/SfE ' - ----------Foundation t10-_----------_ Prop. Line _.=� 7______. __ REPAIR/ADDITION(Prev. Sanitation Permit# _______-.______--------------------------- Date _____ ____ ____________________) SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- --------------------------------------------------------•- Disposal Field (Specify'Requirements) -___________ 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. Home owner or licen- sed agents signature certifies the following: I "I certify that in the performance of the work for which this permit is issued, I shall not employlany person in such manner as to becom object to Workman's Compensation laws of California." N Signed --- --- ------ - - ---------= -cam �- Owner BY •------------------------ `Tits - ------ than owner) FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY ---- a ----------------------------------- DATE ------ BUILDINGPERMIT ISSUED ---- - ----------------------------------------------------------------------------------------DATE - -------------------------------------- "N:ADDITIONAL COMMENTS ----- - - -- - -------------------------------------------------------------- ----- - - - - - ------ F1 ----- -- �---- --- ---------- -----------------------------•--- ------------------------------------------------ ------------.-D-a--t- ---- - - ------- ----- Fi -e-----� SAN JOAQUIN LOCAL HEALTH DISTRICT '" E. H. 9 1-'68 Rev. 5M 4