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FOR OFFICE USE: _ APPLICATION FOR SANITATION PERMIT :....._.. Permit No. (Complete In Triplicate) ..._..._.. - , . --••••••.........................................I This Permit Expires 1 Year From Date Issued 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 Countg Ordinan No. 54 and existing Rules and Regulations.- JOB egulations:JOB ADDRESS/LOC ON -...._...` ..... .. .. ... ............. 44�6!w jgM..................CENSUS TRACT .......................... Owner's Name ...- c� Phone ..............__................. . Address ,.. .. �.�.. ?. ...._..._. ... .. ......................I........ City ..__ ._ .. .. ....,.....................I...............I......... Contractor's Name _-- _ .. License ..>Phone ............................ Installation will.serve: Residence Apartment House❑ Commercial❑Trailer Court 0 Motel0 Other ............................................ Number of living units_____________ Number of bedroomsI Garbage Grinder Lot Size ''-��- - Water Supply: Public System and name ..-•:------ .- __ ............Private Character of soil too depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom Clay Loam ❑ Hardpan ❑ Adobe❑ Fill Material ............ if yes,type ............... ............ (Plot pian, 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 see ge .pit permitted if public-sewer is available within 200 feet,l ! F. /a f- PACKAGE TREATMENT ( ] SEPTIC TANK{ Size_.........-1t.. .f?_.__.-,1i-..,, .. ,- __. Liquid ........ . Depth ...y:... - . +1 Capacity --AP-D--------_ Type.Material..: No. Compartments ... ? ........... Distance to nearest: Well ............Foundation -----/_ .. Prop. Line .._.,9._ LEACHING LINENo. of Lines _.__:..��___-_ ..___- Length of each line..... ... ... .......... Total en t 'D' Box ------1--_ Type Filter Materia# ...,S., ------Depth .Filter Material ._...�.�r...rr---•---------------------•-,� Distance to nearest: Well _....•S _- Foundation.._ • �..-` �.-. Property Line � ... ... SEEPAGE PIT De th ._.��Diameter ._.._,_ [ p ` T.�r_..__-- Number ...... ................ Rock Filled Yes, No t Water Table Depth ..---..._- - - -----------------••---Rock Size .1 Distance to nearest: Well _..__..__.�' �. -._--- Foundation ..-),� --- Prop. Line .. .... ... REPAIR/ADDITION(Prev. Sanitation Permit'# --------___---------------- --_ - Date ....._.. ...... .................. Septic Tank (Specify Requirements). ...........................--••------------ ..................... ..................... _.�..,.r Disposal Field (Specify Requirements) ..................... ---------------- -•----------------------------------------------------------------------------- ...............I........................................1--............................. (Draw •-------------- --••---------------------------•..__.........---•------------......--------...........---••-..........._..._.._..-------------- (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 maturer as to become subject to Workman's Compensation laws of California." Signed ...... -_---------------------- Owner By --------------------------------- � ... •-- e� Title ...�.-er11.19 o---- (If other than owner} _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y rDATE BUILDING PERMIT ISSUED -------------------------•--. ....-------•--._DATE ...._.......--------- ADDITIONAL COMMENTS ------- i ----------------- � - ......... _._..... - • - -- 417.-4_------- .... ....•------_------ ---- •------..__:---Date �."� -Final Inspection by:/,*" .... -------------------------------------------- EH . - Ei 13 2h 1-68 Rev, 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M i