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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No: ----------- ------ € --- - ------ - -- - (Complete in Triplicate) ------------ Date Issued -1 L-Z3_:-7-•l ' This Permit trxpires � 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 Regulations. CENSUS TRACT ----------- -------------- k JOB ADDRESS/LOCAT ON .. ----- --- Phae =Owner's Name -- - - -----.-- - CitY -- ------- -------------- - ---- Address ----.- --------- -------=--- - Contractor's Name --- ------ -- --- -- --- - .License # �� 3 _' Phone Installation will serve: Residence[p Apartment House Commercial ❑Trailer Court ❑ -Motel ❑Other ---------------------------------------- Number -------Number of living units------f------ Number of bedrooms __ '`---Garbage Grinder ------ Lot Size ----------------------------------- Water Supply: Public System and name ----------_-_--_------ F --- -- .<'------ ------------------•--------------•-Private ❑ Character of soil to a depth of 3 feet: Sand'Q Silt❑ Clay ❑ Peat El Loam [Clay Loam;❑ a Hardpan ❑ Adobe n Fill Material ---- ------- If yes,type ------------------ Plot Ian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on 'reverse side.) ( p NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is�avaiiable within 200 feet,] i SEPTIC TANK L Size `r} - x.�Q_:_X ✓X---'----- ----- Liquid Depth -._ a O . PACKAGE TREATMENT { ] >. �-�"--- 6- Material_ No. Compartments __ ----- •-------=• Capacity [70-U Type ----- Prop. Line ------''�- Distance fio nearest: Well -------- Foundation LQ.------ I LEACHING LINE [ No. of Lines -----_ -------------- Length of each line ------------------------ Total Length ------------ __� d--- D' Box --_ Type Filter Material --_ ,R-------Depth Filter Material _-1_�1----:-------------------------- V Founda#ion _- l:�_!. -- Property=Line- :�---.-------•----- I Distance to nearest: Well -_Igo------ --- -------- ^/ ' I 14'r-I_--- Number --_-_-- - -_---- ----- Rock Filled Yes � No I❑ SEEPAGE PIT [ 7 Depth -.--a�_�_ ------ Diameter _ - - - Water Table Depth -------------- -- ---Rock Size f 1� .............. Distance to nearest: Well __- ____-j.___- ------- Prop. Line -----5-------- ----------------------Foundation --------- ---- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------ ------------------- - ----------------------------------------------------------- ----------- Disposal Field (Specify Requirements) ----------- ------------------------------------------------------------------------------------------------------------ ------------ ---------------------------------------------------------------- ----------------------- 1 ------- --�. �- gid• ----------------------------- -------------- - ----- ---- - _ = = == (Draw existing and required addition on reverse side) k I hereby certify that 1 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ---------- ---------- ---------- - - - - --- ------ - ------------ Owner ---- Title ""Y------------- (if other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .-- --:_ -- - ------------------------------------------- -----. DATE DAT --- -------------------------- -------- -- BUILDING PERMIT ISSUED -------------------------------------------------------------- ----------- ---------------=------- ADDITIONAL COMMENTS ---_-- - --------------------- ----------------- ----------------------------------- -T--- -- - -- : -- - W Date Final Inspectign,b SAN JOAQUIN LOCAL HEALTH DISTRICT F H 9 1-'68 Rev. 5M