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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued/41_-:5 - Y 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 , _ -_____ _- ---" s Owner's Name , � -------CENSUS TRACT ----------------------•- • - _X -------- y --------------------------------------------------- Address �-�-� � 1 -------- Phone - -----------------------•--------- 7 - '.- = - �" ._. City _01115;0117010` ------------------------------------------- Contractor's Name ------- -----License #, 1 �� ---- Phone ---------- ----------- Installation will serve: Residence.04 Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other or Number of living units:.._ Number of bedrooms _____Garbage Grinder +1'--- Lot Size Water Supply: Public System and name ___________________________ ______Private - ----------------- Character of soil to a depth of 3 feet. Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Hardpan ❑ Adobeo- Fill Material __._.____ If yes, type ---------------------------- (Plot _______________)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 savailable within 200 feet,) PACKAGE TREATMENT [ SEPTIC TANK Q Size__4/X/V---X-_'" -- --------- Liquid Depth � ------------------ Capacity _.______ : ___Capacity y Q__-- Type ,E' A/- Material dIP404 & No. Compartments _.,, -------------- ---------------------- Distance ______-- -_- Distance to nearest: Well _ _____ -- �f .Foundation1�________ _______ Prop. Line __ LEACHING LINE JX No. of.Lines g -- ---- ---- ------------- Len th of each li a-- =��-------------_-- Total length _��_...-----_-__-- 'D' Box - Type Filter Mater 1/ ,A _ _--Depth Filter Material A1�1'1______ Distance to nearest: Well.. _____,Foundation _ -- . _ /-$> ----- --------}Property Liner ,_ __ ____---».• SEEPAGE PIT [ ] Depth -------------------- Diameter.---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ � Water Table Depth ------------- -------------------------- -------Rock Size ----------------------------- Distance to nearest: Well .---------------------------------------Foundation ----------------_ -- Prop. Line ---------------....... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------_-- ) Septic Tank (Specify Requirements) Disposal Field (Specify Requirements) ______________ __ ------------------------- ----------- I ------------- ----------- ! ------------ - - ----------------- - ------------------------------------------------------------------------------ ------- -- --- - ------ - - -- - - - - - - - - -------------------------------- (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, 1 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 ow er) - { FOR .DEPARTMENT'U5E ONLY APPLICATION ACCEPTED BY _ . .. ' .(� BUILDING PERMIT ISSUED DATE ADDITIONAL COMMENTS ---------------------- ---- ------ -------------- - ------------- ------------- - ---DATE -------------- ---------------------------------------------- ----------------------- --------------------------------------------------------------------------------------------------------------------------------- ------------------------------ -------------------------------------------------------- ---- --------------------------------- Final Inspection b P Y -----.Date ----AV SAN JOAQUIN LOCAL HEALTH DISTRICT y E. H. 9 1-'68 Rev. 5M. I