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FOR OFFICE USE: <br />'i1 2 <br />APPLICATION FOR SANITATION PERMIT <br />(Complete in Triplicate) <br />This Permit Expires I Year From Date Issued <br />Permit No. <br />Dote Issued <br />Application is herebry made to the San Joaquin Local Health District for a permit to construct and install the work herein <br />described. This application is -node ih;.compliance with County Ordinance No. 549 and existing Rules and Regulations. <br />....CENSUS TRACT <br />JOB ADDRESS/LOCATION <br />Owner's Name ...... ....... .,,Phone <br />........................ <br />Address ---- ...... 1_4� city <br />jo <br />------- <br />?,P <br />Contractor's Name ' Phone ---- <br />Installation will serve- !Residence VApartmentHouseCt Commercial oTraller Court <br />I Motel f--1 Other,........ <br />Number of living unitst J_ Number of bedrooms . 7�'_Gorbage Grinder ...... _,__ Lot Size <br />Private <br />Water Supply. Public System and name ....... .................. ___ ........ ............... --------_---_- ........ ... <br />Character of sail to a depth of 3 feet, Sand C] Silt Clay ❑ Peat C] Sandy Loam -ITXC�Iciy Loom,F <br />LZ_J <br />Hardpan Q Adobe 0 Fill Material ..... If Yes, type <br />k <br />(Plot pion, showing size of lot,,! location of system in relation to wells, buildings, etc must be placed on reverse side.) <br />NEW INSTALLATION. iNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br />PACKAGE TREATMENT f `1 SEPTICTANKI I �Size­_­­ . . . . ....... Liquid Depth .................. <br />.. <br />Capacity --- Material............... ....... No, Compartments .... <br />Distance to nearest: Well Foundation .__ ......... __ Prop. Line __ ...... . <br />I............ <br />LEACHING UNE -1 No. of.Lines .......... ...,Length of each line ... . .... Total Length ........... ................. <br />'D' Boxt.._ J.- Type Filter'Material .,..-.Depth Filter Material <br />Distance to nearest. _Well ..................... Foundation ... ......... Property Line ...... <br />SEEPAGE PIT Depth Diameter ............ . . Number ...........:.........1 Rock Filled Yes El No <br />Water I I able Depth ......................,....,._.......,......_....._Rock Size ....... ... ... <br />Distance to nearest: Well _..,.......,.,w ...._,.-....:.. . ...Foundation .... Prop. Line .... .... ............ <br />REPAIR./ADDITION'(Prev, Sanitation Permit# ............. . ..... _ .. . ...... ­­­ fixate .... ..... . ..... .............. <br />3 <br />Septic Tank iSpecify Requirements) ......................... . .. . ..... .. ............. . . ................. .......... ......... ....... <br />Disposal Field "(Specify,..,......y...........-._................... ........ ....... ...... <br />------------- <br />(Drow existing and required addition on reverse side) <br />I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br />County Ordinances, State Laws) and Rules and Regulations of the Son Joaquin Local Health District. Home owner Or licen- <br />sed agents signature certifies the following: person in such manner <br />"I ccertifytal�in the performance of the work for which this permit is issued, I shall not employ an Y P <br />as to be ome subject to WOTICM6S Compensation IOWS Of California,'' <br />Signed -------- <br />...... Owner <br />. .......... <br />By ...... Jitle ............ e6. <br />n <br />(!f <br />than f 'er owner <br />FOR DEPARTMENT USE ONLY <br />APPLICATION, ACCEPTED BY ........ ......... DATE <br />BUILDING PERMIT ISSUED,..... ........... ........ ............... ..... .. ......... .......... ............ <br />ADDITIONAL COMMENTS ....... .......... ............. ....... ............. ....... <br />.......... ­ ........ ...... <br />..... ...... .......... ......... 1I.—I ..... <br />Final Inspect10 n by <br />.. ......... <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />E. H. 9 1 -'68 Rev, 5M <br />0_0 <br />