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4 FOR OFFICE USE. R APPLICATION FOR SANITATION PERMIT .. .:................ -........-- •--------•--- Permit Na. ..................... (Complete in Triplicate) ...........................................I............. i iS 7� ...........:................:............................ 'his Permit Expires t Year From Date Issued Date 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`Ruies and Regulations: JOB ADDRESS/LOC N ---_-.CENSUS TRACT .......................... Owner's Name .... � 1.. - •- - . ...Phone �_...' S''r� Address .. --- ------ ---- 3 -= city .............. - ,.� License Phone 6.� " .� Contractor's Name .---- ---------- ---------• ._._:.-". +kms-----•--- ---- t Installation will serve: Residence Apartment House Commerr#al[]Trailer Court 0 Motel 0 Other Number of living,units:_._:: - `"Number of`bedrooms 5 Garbage Grinder Lot Size �'. -... 1.........- •-•-••-• Water Supply: Public System and name _ . ----. - -;. .......................-- . ..•-----------------------,..-..-............-------..................Private ---- ---- - Character of soil to a depth of 3 feet: Sand n Silt.b"� Clay 0 Peat❑ Sandy Loom p Clay Loam [] I Hardpan Adobe fill Material ............ If yes,type............... ............ (Plot plan, showing size of lot, location of system Jn gelation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tan k.:or"..seiapage pit permitted if public sewer is available within 200 feet,l PACKAGE TREATMENT [ 3. SEPTIC TAhI#G ] Size................• ............................................... Liquid depth ----•--..-......... Capacity ---_-------------_ Tye ....___.. ."..'..-Materlal_------------- - W—Coinpartments ................._...� Distance to nearest: Well _--."0'Prop. Line ................ •---------• =.. Foundation . ...... LEACHING LINE [ ] No. of Lines - ------------•------_. Length of each line-----_--------- -.--Total-Length. ............................ � ' -- '#Y Box .... Type Filter Material ....................Depth Filter Material .............•-1........-..........:........ � Distance to nearest: Well -------------T_:_......TFoundation ......................... Property Line .._._.........._._..---�. SEEPAGE PIT Depth I _ C [ 1 p --•,---------- •--•-• Diameter ................ Number .......__...- •--- ... ..:. 'Rock Yes No IWater Table Depth ..:...Rock Size -------------------------------- Distance to nearest: Well '.................................Foundation --------.-...._ .... Prop. Line ...._...---_----•-- REPAIR/ADDITION 1Prev. Sanitation Permit 9 . Date "......................[ Septic Tank {Specify Requirements) ^� Disposal Field (Specify Requirements) ____--a ------ ------- --�Q....-- . - �- .-.-. . .._... ..........---..__....•---..._.---••-_--•------...._. ----------- :_........ 3."..x.. -s----- - ---._...• •-------------------- (Draw existing and required yQ - ddition on reverse side) I hereby certify that I have prepared this application and that the work will be done\tin�accordance with San Joaquin County Ordinances, State Laws, and Rules and 'Regulations of the San Joaquin,Local Health:Dlstrfct. Horne owner or licen- sed agents signature certifies the following: ~ "I certify that in the performance of the work far which this permit is issued,t shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." S _ Signed ----------------------------- ---- Own er lit#e --- -- -------- ----------------------•-------.._...By --- ------ --- (if ..... oth t an owner) RTM E USE JONLY, APPLICATION ACCEPTED BY ---- - - ...... ....... ` S ' DATE _...� SIS 7 -------_----•-- BUILDINGPERMIT ISSUED --------------•--------------•----- --------------------•--. ------------- :--;-- ---- ---------------DATE ...._...----------•-•--- ...-...-..-... ADDITIONAL COMMENTS -------------------------------------- --------•--------------------- ............ ............-•--------------------- ---- ---------•----- •--••---.._.. ------------- ------------------------------------- . � ......................................... ------------------------------- ......- ............,.,.__�__.�_/_ _ _ Final Inspection bY. •............................................................................___Date ---5 - 7 EH 13 24 1-68 Rev. 5 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H