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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit Na: ............... This Permit Expires 1 Year From Date Issued Date Issued t V• 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: I JOB ADDRESS/LOCATION _?,!' .1. _ ---•- = - C "v J CENSUS TRACT --------- Owner's Na -E..- - ---------------------- ------------------------ -- --- -.Phone ----------------- ----------. Address .. _..i..p e� city _.(1l Contractor's Name __ _ " ---_._.License # -� y --- -- Phone --------- t Installation will serve; Residen Apartment House❑ Commercial:[]Trailer Court i❑ Motel ❑Other --- ---------------- Number of living units:...... Number of bedrooms _171 --__._Garbage Grinder ------------ Lot Size ..................... _ Water Supply; Public System and name __---_"- - . -- --------- - Private El--- --------•- -•--•-------- -------------- l Character of soil to a depth of 3 feet; Sand Cr Silt❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam,[:] E Hardpan ❑ Adobe ❑ 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 available within 200 feet,) Y PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------ --------- Liquid Depth •-------------- Capacity .---------•-P y -yy-------•--•----- Type -------------------- Material_....---- ---------- No. Compartments -........'....... _..�y Distance to nearest: Well ___-_._ -------------_----_---.Foundation _.___.________-._ Prop. Line ....... •.,_00 LEACHING LINEf �. .. - - j ] No. of Lines .______ Length of each line..____r.._ ---------------- Total Length 'D' Box _ __-_._---_ TypeFilter Material .-_--__-�-----Depth--Filter- te Marial _ - 1 s ................... Distance to nearest: Well .--.-..___. .,,.______ Foundation .- Property Line. __.' ._____._ _., •..... SEEPAGE PIT _ Diameter i ] Depth __. -• Number f_..---------- Rock Filled Yes ❑ =No 0 ! P, Water T6ble'Depth ' -=--`---: `• -••-----------"-------------Rock Size ----- - --------------- i• Distance to nearest; Well _----------•--------------•_..--_--•-..Foundation• --------------- Prop. Line _._._------------_._. .� REPAIR/ADDITION{Prev. Sanitation Permit# __------___----------------____-__._-__-__ Date Septic Tank (Specify Requirements) _---..-_------------- Disposal Field (Specify Requirements) - - - - -----------= 6 F - p - - -------- - -------- --- -- - �1.. - --------- (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 District. Home owner or licen- sed agents signature certifies the following: t "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 ---------- Owner By ----------- -- rTitle .-- -fn--.• s - 0 •----------------- - -------- ------------ - ------- (If other than owner) FOR .DEPARTMENT USE ONLY a APPLICATION ACCEPTED BY_-- -- -------- BUILDING -- --BUILDING PERMIT ISSUED --- -__------ ---------- --------DATE ------•--- •. . -- ---------- ADDITIONAL COMMENTS .- ----- -------�--..._..--•-•--------------- -------•------ --------- --- ------------- -- ••-•-------- ...--•-•---� ------•----------- -•-••- ------•-----------------------------------•-----•------- - ----------------- ......... _---•---------- I -- -------------•--- ----- -- --------------- ................. ---------- Final Inspection by: _. -- / !_ l SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.