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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. .. -_-___-_•_. This Perntlt Expires 1 Year From Da#e Issued date issued .. - Application is hereby mode to the San Joaquin Local Health District for a permit to construct and Install the work herein described. This application is made in compliance wit Count Ordina No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO � -_ ---- -_ ... CENSUS.. .. . .................................... NSV TRACT ......... Owner's Name ...............................................................Phone ......... ...............•.......... Address ......... City ............. ..............._....- ------- f C� Contractor's Name ......... . ... ... .... �/C� ----- ..--......_...License # Phone Installation will serve: Residence RAportment House Commercial ❑Trailer Court 0 Motel ❑Other Number of living units ..... Number of bedrooms _3......Garbage Grinder ............ Lot Size Ater Supply: Public System and name .................................................._....................................................Private , Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan❑ 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 ( I SEPTIC TANK I I Size...... ...&.--J.7.,A..1.2... Liquid Depth ------M................0 Capacity J---A_J9,9 Type --�----- Material................. No. Compartments .e11.............. Distance to nearest: Well .... t/P.0...................Foundation .... Q.t.,....-- Prop. Line ---_,.t1..........0 LEACHING LINE j ] No. of Lines ..-;2---------------- Length of each line---- .... Total length .1710............ 'D' Box .../.___ Type Filter Material _.. Depth Filter Material ... ........................................ Distance to nearest: Well -_-------------------- Foundation ------ ...... Property Line PIT O Depth �-51/�iameter ---------------- Number ...- ----..... -- -_-- Rock Filled Yes No ❑ SEEPAGE,,,` Water Table Depth ------------------------------------------------Rock Size ... - - -• . '? Foundation ------ Prop. Line ................ Distance to nearest: Well -------- ._ 0...._ ...... REPAIR/ADDITION(Prev. Sanitation Permit# ............-------------------•--•----_--- Date .....................I............ ) Septic Tank (Specify Requirements) .................. .. Disposal Field (Specify Requirements) ------------------- ---------------------------------------------- ------------...----•---- .......................... --•-----------•--•-••----- ..............................__.......................... (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. Horne 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 Com ration laws of C fornia." Signed --•---. .. .- Owner p ----- BY (� -------------------- ------- Title --------- ----- ........... --• --•------- (If other than owner) FOR DEPARTMENT SE ONLY �r APPLICATION ACCEPTED BY ---------------- DATE .._...'C cj:.. �J --- - - - - BUILDING PERMIT ISSUED ..-------- ---- --------- ---------------DATE .---............. ADDITIONAL COMMENTS ..............• -•-------------.... ------ - ---------------------------------------------- ------ i --------•---------------- • - -----------.-------- ------------------...----------.-..._-------------- --------.....-........................ .............. ..................... 9i Final Inspection by: _.__.. . --- �. (� Date ... .. --_"-.._ 1-- EH 13 24 1-68 aev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M