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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT g (Complete in Triplicate) Permit No. ............... Date Issued ...�:,�y..7� This Fennit Expires 1 Year from Date Issued 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 Regulot€ons: JOB ADDRESSyy/yyLOCATION .._.__..�. - ------ ------------- ----------CENSUS TRACTj'...-• _-_ •------- Owner's Nall'. ." �.. -_.. -............................. Phone Address . ;city .......... Controctor's Name License ... Phone Installation will serve: Residencejo�Apartment House f] Commercial❑Trailer Court ❑ / Motel ❑Other..........................••--------•-•--•-- Number of living units:__/...... Number of bedrooms -..2...Garbagender ..... Lot Size ................� Water Supply: Public System and name ___________ __ .........................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt l] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam 0 Hardpan j] Adobe 01 Fill Material ...._._..... Ifyes,type............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.I NEIN INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,( PACKAGE TREATMENT ( ] SEPTIC TANK ] Size................................................ Liquid Depth ....--...---..........---- Capacity •---•--------•--- 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 ........................ SEEPAGE PIT Depth -•- Diameter ................ Number ----------,_-_._.--_-..--.-- Rock Filled Yes No Water Table Depth .....:.......... ....Rock Size Distance to nearest: Well ........Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date -- -----.-- - /) Septic Tank (Specify Requirements) �t.j .t°/ l. v� f `�.t'�f tJ.�l d'''ot DisposalField (Specify Requirements) ------------------_------•---••-----------•------------------------------------------------------------ ------•----- ......... .................. .............................. ............... .......................... (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. Ham* 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 Workman's C ensot' r laws California." Signed --- - ---- - -- - -----•------•-..._... - wner BY 3itle /� .�i�--- -- --- -- ------ 1---------- •------------ (if other than owner) _ FORDEPARTIAENT :USE ONLY APPLICATION ACCEPTED BY _-_---- -74 -------- DATE . • .. ._ , .__ .......... BUILDING PERMIT ISSUED ------------- - DATE - --.. --..._---- .. _ ..................... ADDITIONALCOMMENTS .................... ----•-----------.-. -----------••-------------------------------------......................................... ------ - --------- ----- .............................................. -•-•-----• ------------------------------------- ............... ----- ---. -• .. ..........................................--........... ............ Final Inspection b ......................................................Date .. 1H 13 2h 1-68 1 OA IN LOCAL HEALTH DISTRICT 8/71; 3M