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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......................................................... - IComplete In Triplicate) Permit No. .. ....................................................... This Permit Expires 1 Year Frei" Dah Issued Date Issued Application is hereby made to the San Joaquin local Health District for a permit to constrict 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/LOCATI N /•i' * ,1,/``.•,1# ENSUS TRACT .......................... ff Owner's Name ...... � -----•--- -----•.................I............,.-.............................':....Phone Address S' . .. city Contractor's Name ./,� .......License i9t Installation will serve: Residence❑Apartment House Commercial OTrbller Covet Motel ❑Other ............................................. Number of living units:..._.-_--- Number of bedrooms .......::.•-Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ---------•--•-......-----••-•--.............................................................................Private Character of soil to a depth of 3 feet: Sand❑ Slit❑ Clay ❑ Peat❑ Sandy Loom d Clay Loam ❑ Hardpan [} Adob Fill Materlal ... If yes,type ............... ............ (Plot plan, showing size of lot, IOcotion of system In relation to wells, buildings, etc. must be placed on reverse. side.) NEW INSTALLATION: (No septictankor seepage pit permitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT ( } SEPTIC TANK{ } Size-----------------_--............................ Liquid Depth .......................... Capacity .................. Type .... ............... Material...................... No. Compartments ...................... Distance to nearest: Well .........................:..........Foundation ....................... Prop. Line ...................... LEACHING LINE ( } No. of Lines ........................ Length of each line............................. Total Length ......_...._......_....._... :.� D' Sox .. ...._... Type Filter Materlal ...._.....Depth-fiiter'Materiat ........_'i i - •_ Distance to nearest: Well ........................ Foundation ..............:.......... Property Line ........................ SEEPAGE PIT { ) Depth ..... .............. Diameter Number Rock Filed Yes ❑ No , Water Table Depth ................................................Rock Size ---............. -------------- Distance to nearest: Well t .............................--._-__--..Foundation .----- --.._.—..- --- )Prop. Line -----.•- ............ C REPAIR/ADDITION(Prov. Sanitation Permit` ............................................ Date _...._..__._______.:............. , i Septic Tank (Specify Requirements.........___ ------- Disposal Field fSpecify(SpecifyRequirements) -•-------------------------- .................. ------------------------------------------.............•..................... .................... ' (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 Son Joaquin Local Health.Dlsreld. Home owner er Ilcen- 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 manner as to become subject to Workman's Compensation laws of California.•' Signed - -------- --------------- �_... Owner BY ---- ----------- - ` Title _ .. {if other than o r) I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ..-.- ---- ------ ----------..- DATE ............ ._.. .. _... _ ...... BUILDING PERMIT ISSUED -------- --------- - -------I _ —-- DATE ......_........•-- -_...------•---•--•......... ........................ ._... 11-1 ................ .....---------.----------------------------------................ ADDITIONAL COMMENTS . ......... ... ..................... i -�Final Inspection by: --._-- --:... .. .............................................. Date ...... EH 13 21a 1-68 Rev. yy SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M E