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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No - -- 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 County Ordinance No. 5.49 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._I... _ �- - CENSUS TRACT Lc (.... --.. . . . ............ Owner's Name ..._-__-- e g... . Phan Address . -...-. �-........ - ..... h-l . city ... .. . ..................... Contractor's Name ---- - License i .d. �r Phone u ---... .............................. Installation will serve: Residence Apartment Ho sefl Commercial 0 railer Court 0 Motel ❑OtheXG --- ._..... Number of living units:... -fid.__ Number of bedrooms ............Garbage Grinder ............ Lot Size Water Supply: Public System and name ........................................................ ..Private [� _....... ............I..... ........ Character of soil to a depth of 3 feet: Sand L] Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ 1 Hardpan ❑ Adobe•❑ Fill Material --- ........ If yes,type ..........r.. ............ (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc.' must be piaced on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT I ] SEPTIC TANK f ] Size............... . Liquid Depth .......................... Capacity .. Material............... ... No. Compartments Distance.to nearest: Well -----................................Foundation ...................... Prop. Line ...................... LEACHING LINE .[.I No. of Lines ------------------------ Length of each line............................ Total Length ................ 'a--Box. ............ Type Filter Material ....................Depth Filter Material Distance to nearest: Well ------- ...... --------- Foundation .--......- ............. Property Line ........................ SEEPAGE PIT ( I 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) --------------•--- ------------... --- -------...-------•-----------••---•-- _......... - 1 Tom......._.-. Disposal Field (Specify Requirements) ...� --__ - s-----------------------I-----------------I--------------62 ,,,� -----------------------------------------------------------------------.-------------------- (Draw existing and required addition on reverse side) 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: j "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 Workma ' Compensation laws of California." Signed --. --- ----- - • ------ . • ..... - BY ---------•-•--- Owner Of other than owner) Titl � FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .---L:_ .__ -----. DATE ... •: BUILDING PERMIT ISSUED ----•---------- .. ------------ --DATE .......................... ADDITIONAL COMMENTS --------------.............. _-- - --------------------•--.- .--------------•-• ----.........------ ---------------- - Final Inspection by: ----- -- - Date .. 3 EH 13 2b 1--68 flev. .r•M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M