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FOR OFFICE USE: --21,------------- frb APPLICATION FOR SANITATION PERMIT - -...-..... (Complete in Triplicate) "........................- Permit No. . �.... cf . .....................................I..............-.. This Permit(Expires ] 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._.._ 4�.AF...... .. .0 ..-. ZZ ENSUS TRACT ..................... .•-•- Owner's Name ..........• .................................Add --•..............Phone. �1.-.........-............. �" "��--•-•-- ----•---------------�--------•--. City .... .. ---.. Contractor's Name .._ ------------------License Phone . . .` ._ Installation will serve: Residence ❑Apartment House Commercial❑Trailer Court 0 Motel ❑Other .:................. Number of living units:---- Number of bedrooms ______Garbage Grinder ............ Lot Size ....� �..r............ Water Supply: Public-System and name -----------•......................._.---......--........_-----.............-••--••-•-•..____..__._...._.._...PrivateA Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Cloy Loam ❑ Hardpan ❑ Adobe 0 Fill Material ..._........if yes,type............... ............ (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tonic or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK[ ] Size-.... ................... Liquid Depth ......... Capacity ---L-D_Q_____ Type .n c��-e _ Material__ No. Compartments .....��.—......... ,6 Distance to nearest: Well -----_f_Q........................Foundation ../0.............. Prop. Line ..............-0 LEACHING LINE [ ] No. of Lines -----Z-------------- length of each. Ii;te..�C1......------------- Total Length�Aa.0............00,! 'D' Box �Cx1 _._ Type Filter Material 1-z?4_l_-__.Depth Filter Material ....-iee........................... . r Distance to nearest: Well -,/--d7-4....... ---... Foundation _._,/<D............. Property Line .....'......... � SEEPAGE PIT [ ] Depth ____________________ Diameter Number ............................ Rock Filled Yes ❑ No ❑�. d Water Table Depth ----------- ....................................Rock Size ----------- -----•--.... ....... A Distance to nearest: Well ...._...................................Foundation .................... Prop. Line ..................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..................................I SepticTank (Specify Requirements) --- -------------•-------------------•-- ............-•---------------- ...........__---......................-........--•----.......... DisposalField (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 Son Joaquin Local Health.Dlstrict. Nonce 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 ..... �,..�c ,t,l ------- -------- Owner By -------------- -- ---------------- Yitle - - yf other than owner) OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- ---------------- -------------------------- -11 DATE .�,2`/`7.' �_ . ----..._...•.----- BUILDINGPERMIT ISSUED ------------------------- - •------------------ ------ -----------------------------DATE .................. ------- --------------- ADDITIONAt_ COMMENTS ........... ............................... - --- -------- ------------ ----------- Final Inspection by: --- ------------------ ------------------------------------ _._._..---•-•--..._-.-Date� � ._'� __..._.-..---- EH 1.3 2b 1-68 Rev, � SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M