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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / , (Complete in Triplicate) Permit No. ------. ------------- This Permit Expires 1 Year FMm 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. 549 and existing Rules and Regulations: JOB ADDRES S/LOCATI N ---...... ¢"` �'` ------ ---- -----CENSUS TRACT ---------- ----------- Owner's Name X^ Z "�- -------- - - ----------------Phone---------- Address - i _ _______/j- ----- - -- - -�.-a----- City Contractor s.Name --J/--- ------- ----- Phane ------------------- a ------ Installation will serve: Residence' Apartment House❑ Commercial ❑Trailer Court i❑ / l _ ll .Motel gOtheh_----------------------------------------- --- Number of living units:----1__.___ Number of bedrooms �_____Ga;bage- Grinder _. ______ Lot Size ___ ----- t Water Supply: Public System and name --------------------- --------------------------------`- '- ---f----'Private I . Character of soil to a depth of 3 feet: Sand'❑ �It❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 0 Hardpan V Adobe-E]—Fill-Material _____ .___ If•yes;type ------- -----------_ _~---- (Plot plan, showing size of lot, locatio tof system Lin relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seep a �it permitted if�/��plic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK —'�- ` lSize_�l _ _l�_�_ __._ ..r_________ Liquid Depth --- ________.:_...._. �} Capacity _-JS ----- ----- Type - ----_- Material---- ------`'`fir-- No. Compartments - -------------- if # g o r Foundation --------- Pro Line -------- DistanceS `____ LEACHING LINE [ Noof Line nea--st- Wellti Length.-of_each-line,-..-.1_ r�---_-._r Total Leng h _..--.__....__ O fl rD' Box __-- ------ Type Filter Material _____________Depth Filter Material ____/f_________________________________ Distance nearest: Well _.__.fO__�_________ Foundation 4------ O--'--------- Property Line. __-S_�___ _.. SEEPAGE PIT Depth .S Diameter ___` _�r_ Number .__ _._ — `t Rock Filled Yes [ ' No • Water Table Depth --------------- ---------------Rocks Size --------- Distance to nearest: Well ------------- bp------------------Foundation __fA_f---------- Prop. Line ---1--------------- REPAIR/ADDITION[Prev. Sanitation Permit# ------------------------------ - Date z____.____-_--_----------.-____-} g SepticTank (Specify Requirements) --- ------------------------------------------------------------------------------------------------------------.. ----------------------- -- Disposal Field (Specify Requirements) ------------------------------------------- - �. ------------ ------------------------------------------------------------------------- ---- --- -------------------------------------- --•--------- --- ------ -------------------- - ---------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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: "!_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 kman's Compensa ' n laws of California." Signed/.H- ---------- ---------------- By --------------By -------- --- ------ �"t�s'" Title -i. ! -------- ------ I (If other than owner) E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - - -- -------- --------------------_/- DATE BUILDING PERMIT ISSUED ------------- ------------ DATE ------------------ ADDITIONALCOMMENTS ----------------------------------------------- --------- --------------------------------------------------------------------- --------------------------. a -------------------------------------------------- ------------------------------------------- --------------------------------------------------------------------------------------------------------- --- --- -------- - Final Inspection b ---------------------------------------------------------Date _..". ----- -- ---------=------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M