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y- FOR OFFICE USE: ; APPLICATION FOR SANITATION PERMIT Permit N - ................................. . .......... -'-�•- o. . /.-3 - (Complete in Triplicate) ._.. This Permit Expires 1 Year From Date Issued Date Issued .". ......3 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: E / ,•� � gf2v�Gafh/nJ-P ! -........CENSUS TRACT ---- -_--------_---- JOB ADDRESS/LOCATION .._.L._.�.'7 _. .._W---- -- Owner's Name --- / U.11� � ....................... Phone �j � h' Z Address � � 7E -� + .- ...:_.. CityZit%� I //. �� E --------License T --- Phone Contractor's Name - Installation will serve: Residence Apartment House-F-1 Commercial :❑Trailer Court 0 IMotel ❑Other --------- ----------------------------- Number of living units:.-./...... Number of bedrooms _,.ate..-----Garbage Grinder ___.. .... Lot Size -------------------- ------------------------ ----PrivateK Water __________ _________.--------------------- Water Supply: Public System and name _--. Privateer Peat Sand Loam Clay Loam ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ ❑ Y ❑ SHardpan ❑ Adobe; Fill Material .-.___ If yes,type ---------------------------- (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 pu/eai.er is available wi in 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK( ] Size-.._------- ---- iquid .Depth -----------------.__;.. l Capacity -------- Type -----•----------- -- Mat --- -------------- o. Compartments ---------•-------._.._. �l I Distance to nearest; Well -__--..._._ ndation - .--__.___--._. _, Prop. Line ..................... . Len th of a __-- -_---- ••-- ------ Total Length LEACHING LINE [ ] No. of Lines ._,.____ 9 th Iter Material 'D' Box _... .------ Type Filter Material ___ _________ p Distance to nearest: Well -.... ---------- Fou ---•----------------- Property Line _._........__. .__....-- SEEPAGE PI7 De th Diameter ___._-_-_ Nu _____--________- Rock Filled Yes ❑ Noj] IWater Table Depth k Size ....................---------- - ----- ---------•-.- Distance to`nearest: Well •----------------- ndation . --------- Prop. Line -------------------_- 1 ----- ---------- Date ---------------------•--`-•-•:---) ; REPAIR/ADDITION(Prev. Sanitation Permit# ----• ------------ --•---- Septic Tank (Specify Requirements) -- _----- t ��! _--- V--- Disposa Field (Specify Requirements)�__L9�.... � — , 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 Son Joaquin I' County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lieen- I sed agents signature certifies the folIowl ng: arson [n such manner E "1 certify that in the performance of the work for Which this permit is issued, I shalt not employ,cmy p !( as to become subject to Workman's Compensation laws of California." ( -Signed 51 ................ Owner ` - --- -- ------ ----.•- .... Title - ----- -- ---------- --- ------- ..-------------. _ --------- (If of er than owner) FOR DEPARTM T NLY ' <. .:. . . DATE `� �. -� ------- APPLICATION ACCEPTED BY ------------------------------------ ....__....DATE -------- --•--- BUILDING PERMIT ISSUED •- _. .. ADDITIONALCOMMENTS --------- ----•---•-••---...----.... ...... ------------_-----_--- { ----------------------------•------•----------------- ---•--------•------------•---------------- - ......................Inspection •__- - ------- ----- SAN JOAQUIN LOCAL.HEALTH D TRICT r " E. H. 9 1-'68 Rev. 5M