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. OR OFFICE USE: M APPLICATION FOR SANITATION PERMIT ------ ------------------- ----------- ----- (Complete in Triplicate) Permit No: - -'---- This Permit Expires 1 Year From Date issued Date Issued f 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 *th County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION .-_I(_ � - „__-- - , ` ----------------------- - -----CENSUS TRACT " ----------- --------- ---------------------------------- Name _.-'�_ __,-- __- _ •----------- ------------- ------ Phone Address ------ f - - ---------- ----------- Contractor's Name - �_� ----------------------------------------------- -- -0- License # &t,3 _ Phone 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 name _ Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam E] Clay-Loam- - _m _❑ f Hardpan Adobe❑ Fill Material ------------ If es, Y type ----------- -- - - . J (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 [ ] SEPTICTANK /' [ Size-_ - Jf�---_-- / R< a --~�" - Liquid Depth Capacity AQ-� TYPe _ Material__ , No. Compartments O Distance to neaest: Well -------_,,f�--------------------Foundation ---��_---;--------_ Prop. Line �-------:----_--- LEACHING LINE f ]� No. o{ Lines 3 � L� ----- Length of each line----- ------------------ Total Length 1 ' 'D' Box -_�_.____- Type Filter Material --_191ki-----Depth Filter Material -------1_ Distance to nearest: Well -----5p_J----------- Foundationd SEEPAGE PIT --r--•------•- --�--�— O Depth Diameter ---------------- Property Line _-__ Number ------------------ _____-_ Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------------------------------Rock Size ----- Distance to nearest: Well ----------------- ____.__Foundation ---------------- _ Prop. Line .------------------- - ------------------- _ REAIRADDITION(Prey. Sanitation Permit# -------------------------------------------- DateSeptic ---------_----- Tank (Specify Requirements) ---_:___.___:______._ ---------------------------------- Disposal Field (Specify Requirements) ---------------- - - - ---- - --------------- -------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepareal 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) # -- -" FOR .DEPARTMENT USE ONLY � APPLICATION ACCEPTED 8Y .. --- - - __ --__--_-. DATE - _` -2—"�l BUILDING PERMIT ISSUED ------- ----°---- - •---- •--------- -------- r ------------------------------------------------------------------- ----------- TIONAL COMMENTS ----- "---------! ------- -------- - - ATE ---- -------------------- - ----------- - -------------------------- --------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- Final Ins ection b ---------- --------------- --------------------------------------------------------- p Y' - --- ----------------------------------------------------------Date _.--��'_� ------Or - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1•'68 Rev. 5M.