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. FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �.......--•;-- • --•............................ Permit ` ® .....................................I�.... (Complete in Triplicate) This Permit Expires 1 Year From Date Issued gate 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 egulations:JOB ADDRESS/LOCATION -..._ . . ....,.... ......._ J .................................CENSUS TRACT ....... .............. Owner's Name ......... .. ...:. ....__.. ......... .. .. ..... Phone . ......... .. ... ...... s Address . l �N �. ......... ---+.................................. City . -- --- ------------- ___ Contractor's Name ... -_.. .... /.L.. .. .. ... ..... _------.License # A477/1,7... Phone Installation will serve: Residence X Apartment House-❑ Commercial []Trailer Court ] _ Motel ❑Other .............................. Number of living units----__.. Number of be room :.....Gdrba�eG_rinder Lot Size .... 11rr�--•••---- �._,._ ''--)) ..................... -.Private Water Supply: Public Systemf and Hama ..... ............. ... fes- --•....._.. ..._._......---------.......-•---• ❑ Character of soil to a depthlfof 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam j] Hardpan ❑ Adobelk Fill Material ..........._ If yes,type ............................ (Plot plan, showing size alb 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 TANKr�'�51z ------------•.................. ........•----.._ Liquid Depth .. Capacity -------------------- Type .................... Material----------- .......... No. Compartments .... ................... .� DisI tance to nearest: Well .....................................Foundation ------._............ Prop. Line ................._... LEACHING LINE No. of lines � .......�------------- Length of each line------,��-•......... Total Length �-�-�--�.._.....-------. VI I 'D' Box Type Filter Material . .._Depth Filter Material ....,.1, , ........ 11 Distance to nearest: Well ..J:ut..Z;/-•�Foundation •_____lQ............. Property Line -•• ........ - G SEEPAGE PIT Depth .J.-�........ 4 II Diameter ._�" ._er Number -------�----------------- Rock Filled Yes [:'' No ❑ Water Table e .......- r .. .............r � LrGe pth IM REPAIR/ADDITION(Prev. Sanitation Permit# ....-....................................... Date ....................•_----------j SepticTank (Specify Requirements) ------------------------------_--_ ....................:......................-.................. ..._............................... ,�9 e Disposal Field (Specify Requirements) ------ -- ------ - *- -�a... ...- ---.... ..... �`" c - ............................................................--............ ................................................. ....................................._._,.................... 11 .. ........................................................ (Draw existing and required addition on reverse side) 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed I Owner 13y .............. I� -l..4�_____- ..........I........._... title . ........... (If other than"owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... .• .. ...................................................................................... DATE ..... ------ BUILDINGPERMIT ISSUED-�...............................................................:........•---•-------•-•-•--..... .........DATE ........................................... ADDITIONALCOMMENTS 1.......................................•....... ...........................•........... .................................................--.................. ..................................--............-........................................................................................................................... ...................... r ..........................................:�k_........._....._.. .................. ........_............ ... .. --- ---- r .................................. ................ .... . .. ............-------... --............._.._._...- Final Inspection by: 'i ..............................Date .... .. _ �j �.. ....._. .------••------------- -- SA JOAQUIN LOCAL HEALTH DISTRICT AA,� 7/72,3 E. H.13 241-'68 Rev. 5M ��^ ----- ,K