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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 7 �3 ...............__....._................... it No.l...._._.' (Complete in Triplicate) PermF + .................. .................................. This Permit Expires 1 Year From Date Issued Date Issued la. .. 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 c mpliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ... ..A5 I ....... CENSUS TRAGI ....................1.111. Owner's Name 1111 -•-- • .. .. ... !1 _ ... .................•••-Phone ------••-----•--•............ ��--- � 1111... Address .......... itY ........................................................ ............. Contractor's Name ..... d ..License # C1'. / ,(, .. Phone'. Installation will serve: Res2ence*Apartment House 0 Commercial ❑Trailer Court MotelC1 Other -------------------------------------------- Number of living units:............ Number of bedroo s ___1111.____Garbage Grinder _........... Lot Size ._. __fC _............... Water Supply: Public System and name __-...C:�. t.. ..._w a........ ........ . . ---.___-.-------•-- = •-----_.-----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 [ ] SEPTICTANK-J ] Size............:................................... Liquid Depth ............ .-._••. 6 Capacity ..............•••... Type .....--............. Material...................... No. Compartments _._......._.....-......5' .. Prop.'Line ,.. - Distance to nearest: Well ....................................Foundation ..............--•--. LEACHING LINE ( ] No, of lines ........................ Length of each line-----------------._......... Total Length'1111...............---1111•, nl _,-. Type Filter Material ....Depth filter Material 'D Bax, 1111 ... T 1.111-•---1111-• 1111--1111---- -..............••---•1111.. ---- Distance to nearest- Well ........................ Foundation Property Line ........................ Depth 111 1 . r _ [ J Ai _�_I Didmeter ___:11____11:'._ Number .......... ...... _ Rack Filled Yes No 1111._ _... �� Y� Water Table Depth ...............................................Rock Size................................ Q Distance to nearest: Well .....Foundation .................... Prop. Line ........__... ......... 1 REPAIR/ADDITION(Prev. Sanitation Permit# _........................................... Date ------------------------ ......... Septic Tank (Specify Requirements) .......................... ------. .......-_-•-- 1111... Disposal Field (Specify Requirements) ...._ �. ................•. Y., -------------------------------------------• -•----..........__................. ._.._.....--1111-- ----------1111.-1111-- --........----------------1111-. ..,. --- -----------------------..............---•-•-------------•----•--•-•-•---.........-•---••-�---- (Draw existing and required addition on reverse side) 1 hereby certify that l 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 net employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed 1111---•--........Iff .. te 11--- - 11111111OwnerBy __...... Title ill ot n ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---.....-- ............. ......... DATE .........1..11. _. .. 7z..--•- BUILDINGPERMIT ISSUED ......---•-----------------------------------------•111............-....................- ...................DATE ........................................ ADDITIONAL COMMENTS ------------- .................--- ................_............... ........................----•........._........--•...__........-•-•••-'.,._.._ ................................................... . . • ---•--.--•._ ..................._........................................................ FinalInspection by: ................ ........... . ... . • _ ..............................................................Date .._ r� ........ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H 1.3 24 1-'68 Rev. 5M 7/72 3 M