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a FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT {Complete in Triplicate) Permit No. ..7. .........................................I......... 1 .. .................. This Permit Expires 1 Year From Date Issued Date Issued ...`71- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described sgcribed This aepjia tion is made compI! e ith�a�unty Ordinance No: 5 9 and axis 'ng Rules and Regulations: r O ADDRESS/ TION . �_:. . . _ _.... ..___.. CENSUS TRACT .......................... Owner's Na .. .. .. .. ............. ..A... .------- & .. ..._.._.. v� ._ 1- .. . ...r Phone Address City Ss Contractor's Name ....... . `..... .. ..........:......License # ./,ft3 _done ........................... Installation will serve: Residence [3 Apartment H use❑ Commercial ❑Trailer Court j] MotelEl Other ----•- -•---------•---------------•--- Number of living units:.__.. •-_.---_ Number of bedrooms ___ .Garbage Grinder ------------ Lot Size ............................ -....: U Water Supply: Public System and name ................................-------------------------..............................................•------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom C] Clay loam ®/ L Hardpan ❑ " Adobe ❑ Fill Material ............ If yes,type ............................ 1 (Plot plan, showing size of lot, location of:..system in relation to wells, buildings, etc. must be placed on reverse side.) i NEW INSTALLATION: (No septic tank or seepage pit Permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ l Size_;5.__/ ................. Liquid Depth .._, _. --.-- p `� Capacity_. '4D - Type Material a.; Compartments ........... .. ...... Distance .to. neo est: Well ......... .........Foundation _._ C1. Prop. Line LEACHING LINE No. of Lines..............L-•___i_-_-. length o each line------- __-_- ... Total .length 'D, Box_.:�.. Type.-•Filter Material -----Depth ilfier tenial ...': .1C.............•-•-.-.--. .. ; .. / -�Distance-to. near �st: Well .....��'G .. Fo-undation' .--1: .....=--- Property Line SEEPAGE PIT [ Depth .-_ . __ Diameter __. .__.____ Number ....... ............ .... Rock Filled Yes [ No Water Table`De th .. ..... .-- _.. .- -l� ..J r3 f�_.. . p --_-- .._..Rork Size -. �?-•.. � Distance to nearest: Well �r .J ......Foundation ..../4. Prop. Line .....?._�G�_..._. REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .............................. � Septic Tank {specify Requirements} .. ................................- ............................ DisposalField (Specify Requirementsl ..................................... •-•---•--------- •--••---••-----••.......•--•••--••-•--:•-----.._..._. ........................ 1 � 1 ..............................................._.__._.................................................................................___•.....__........... ..__._..._._._.....________..__-__.______ ............................................... _--_____--_______..__............_..____.I................................... - (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. 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 Wor a 's Compens laws of California." E Signed ........ ..... . : ....... . .... ----— Own1-yr4adIA ............. �.......... Title -----_------ (If other than owner) FOR DEPARTMENT USE ONLY � APPLICATION ACCEPTED BY . ............. ........ . ....•---•-----•-------......__._...,.__..........---..............., DATE ....... BUILDINGPERMIT ISSUED ............................................. ...............................................=..............DATE ........-----•--...-••............ ........ ADDITIONAL COMMENTS , ..... ...... ... ..�.. � ----. ................................................. •-•------••- •..... .. .........•-•-•------•------••--•.._ --Dat � ......FinalInspection hY - - . v SAN JOAQUIN LOCAL' HEALTH DISTRICT E. H.1.3 241-'68 Rev. 5M x_7/72 3 214 a