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POR OFFICE USEIV`- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. t ------ ------------ This Permit Expires i Year From Date Issued Date Issued ------------------ L 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 .___3_7�,�`__--_ �/� CENSUS TRACT Owner's Name - I _ ,-c --- ----- ------- -------Phone.916—Y ----------------------------------- Address '. __ ----------------- Cit --------- Contractor's Name ___,� � �,�� ----------------------------------license # - ----- . 'l ------- Phone __`� ln�7_ Installation will serve: V�denceartment ❑Apartment House.ircommercial . Trailer 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 feet: Sand'❑ Silt.[] Clay Peat❑ Spndy Loam••❑ Clay Loam_❑ Hardpan 0 Adobe [] Fill Material ------ Iftyp,esa ______ Y .(Plot plan,plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side:) NEW INSTALLATION: • (No septic tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ------ ----------- opacity ---=---------------- Type -------------------- Material--------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------.----- LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------------------- ------ Total Length ----------------------•---- 'D' Box ------------ Type Filter Material ____________________Depth Filter Material ________ Distance to nearest: Well ------------------------ Foundation ------___ -- Property Line ' ----- EPAGE PIT [ ) Depth ------ --- --------- Diameter —�� ---------------- Number ---------------------------- Rock Filled Yes ❑ No .0 Water Table Depth ------------------------------------------------Rock Size --- ------------ ----•- t Distance to nearest: Well ________________________________ _Foundation I Prop. Line -. REPAIR/ADDITION(Prev. Sanitation Permit# _____________________________ } -------- ------ Date ----- ------------•----------- --- Septic Tank (Specify Requirements) ---------------------------------------- - -- - - ------------------- isposal Field (Specify Requirements)-----W-0, k - - ------------- ---- - --------------------------------------------- ------- ------- - - - --- -------------------------------------------------=------------------------------------- (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, I shall not employ any person in such manner as to become ubjec o/Workman's Compensation Laws of CaliFornisa." i Signed ------ l./-�dG1d �//V ---- --- ---- wner BY - rQTitle----------- ----------- (------ ---------------- 'pof owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---C-i--- --_ -_ BUILDING PERMIT ISSUED _-- -� DATE _. _ t._ -°)-�--------------- ADDITIO AL OMM T _ - - ---------- _ _ _ _ _. ._t-________________________________ _ Final Inspection b : - - ---- -------.Date ----- -- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M t far. � I