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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------- .---__.--- This Permit Expires I 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 ma 86 in compliance ith County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO -/' 9-� ------- - --------------------------------CENSUS TRACT Owner's Name -------------------------- Address �.Z g_ f _ -------------------Phone City r Contractor's Name ------- - _ - - -------- License # )699P, Phone ------------- ------------•--- Installation will serve: Residence ❑Apartment House,E] Commercial :[]Trailer Court ;E is is Motel ❑Other Number of living units;--..i------ Number of bedrooms ._ ___Garbage Grinder ._-__.__-._ Lot Size _ - - _ II .............. ' Water Supply: Public System and name ------------------------------------ - Qf - --------------------- - - Private Character of soil to a depth of 3 feet: Sand'Q Silt.O Clay Peat❑ Sandy Loam [] Clay Loam Hardpan ❑ Adobe t7 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 TANK01 Size�------X-/V-----A`r---- ------------ `-'�- Liquid Depth -- -------•---- --- Capacity l�tn4 -- T Ype Material----'P�r4L--- No. Compartments ..__._. _ Distance to neatest. Well -s� p_ "---- -_-:Foundation __-�D___�__.__---__ Prop. Line ._. '_.�_- --.-• rl I LEACHING LINE [ No. of Lines _________I_____________ Length of each line---------/V40-9 __ Total Length 'D' Box -------- --- Type Filter Material ----15--)47t Filter Material __-__ __ -------------------------------- Distance � I f` ---------------------- -- Distance to nearest: Well ---. l.�-------- Foundation ..__ � --__ Pro er Line SEEPAGE PIT [dIll Depth ___- 2- Diameter _ _ Number ----- ------------ -- Rock Filled Yes �No :� T11 t Water Table Depth ------------)a ------------------Rock Size --- Distance -Distance to nearest: Well __.______ -Foundation �� prop. Line ---___-'r-�' REPAIR/ADDITION(Prev. Sanitation ;Permit F# _.-____-.____' - ---------- - Date ) 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. 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 ----------------- - ------------------ BY -- { --- Title '° (If other than owner) 4 I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - - --------- --- DATE 46 T? BUILDING PERMIT ISSUED . ------------------------------------ -------DATE ------------------------- ---------------- ----------------------------------------------------------------COMMENTS ----------- -�------ - - - - - ------ - --------- --- - - - ---- ------- ----------------------------------------=--------------------------- _________________________________________ ------------------------------------------ ---------------------------------------------------------- Final Inspection by: __. __ Date . ."7t�------ ----------- - SAN JOAQUIN LOCAL HEALTH DISTRICT r E. H. 9 1-'68 Rev. 5M c