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rQX OFFICE USE: APPLICATION FOR SANITATION PERMIT )Complete in Triplicate) Permit No. . �.:".3 �. ........... This Permit Expires 1 Year from Date Issued date (slued .. f 76 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 ...... -.. ................ CENSUS TRACT ........... .... Owner's Name ... . . . ,N..-..-- -- -. .. .. .........................................................................Phone Address .... City Contractor's Name ....... ... ... .License # Installation will serve: Residence❑Apartment House❑ Commercial❑Troller Court Motel ❑Other......................•---...-....._ Number of living units:..... -__--- Number of bedrooms �- Garbage Grinder Lot Size �1 Water Supply. Public System and name ..__._____.. Private ❑ Character of soil to a depth of 3 #eet: Sand❑ Sift[] Clay [3 Peat[3 Sandy Loam❑ Clay Loam ) Hardpan ❑ Adobe❑ Fill Mpterlal if yes,type (Plot plan, showing size of lot, location of system In relation to wolfs, 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 TANKI l Size....... --------•---••--••---------. ..I........ Liquid Depth .......................... • Capacity ---•---------------- Type -------- ----------- Material_....__..--.---_- No. Compartments Distance to nearest: Well .....................................Foundation ...................... Prop. Line . LEACHING LINE [ ] No. of Lines ___ _______________ ____ Length of each line.. - ,�/�fotal Length 'D' Box .._._. ----- Type Filter Material .............. Depth Filter Material Distance to nearest: Well ........................ Foundationp �jf ............. Property Line ........................ SEEPAGE PIT { ) Depth/.'(9 9Viometer ................ Number ............1.------_._... Rock Filled Yes No ❑ Water Table Depth ..................... --....------..........Rock Size ......_.... ...... Distance to nearest: Well ........................................Foundation ------------ ....... Prop. Line .................. REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- . - __ Date ._........... .--••- - i Septic Tank (Specify Requirements) ----------- •--- ---•-. - Disposal Field (Specify Requirements) .-___--_-_- (Draw existing and required addition on reverse side) 1 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- J sed agents signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, t shall not employ any person in such manner as to become subject to Workman's mpensation laws of Ca - lifornia." Signed _.... Owner C - BY ........ -- ----- ---- ------ J-itle ........... .. ot r than owner} FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- - -- ---•-------• .-------.-•-.- BUILDING PERMIT ISSUED .-.- ---------------- DATE, ADDITIONAL COMMENTS -._..... DATE ...__._..... --•---------------•-- -------------- --------•-•---------._.._ .... ---• --------------_. --•---•---.....---...- ------------ ...------ _.._. final Inspection bTS - --�---......-. p y ----•----------------•--•--•--._....----...._•--••--•. ..... ..Date EH 13 2b 1--6t1 nev. SAN .IOAOUIN LOCAL HEALTH DISTRICT X74 3F 4