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FOR OFFICE USE: I APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) This Permit Expires 1 Year From Date Issued Permit No.--TZ,-x.5...5 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 ADDRESS/LOCATION--Q�l _.._-___ _------- --F---- -__-- _-- . `----------------------- CENSUS TRACT .......................... Owner's Name .----- Q ------ . Phone .................................... Address 7 r - -� City Contractor's Name ------ .. __ ._._........ ..License # Phone .............................. Installation will serve: Residence ❑ Ap rtment House ❑ Commercial Trailer Court Motel ❑ Other ...__�nVI' Number of living units:'r. Number of bedrooms _-----._Garbage Grinder _v: - Lot Size ......-----_______________________________.. Woter Supply: Public System and name ................_. _ ..¢_^ _ ._,-- ........__. ------------- Private ❑ �_. . Character of soil to a depth of 3 feet: Sand'[j Silt ❑ Clay ❑ Peat ❑ Sandy. Loam Clay Loam Hardpan ❑ Adobe .❑ Fill Material .--- .__..--- If yes, type ------..-.._ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seeL7age pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT (] SEPTIC TANK Size_..... �.-.........r%.......___�`z..._"____ Liquid Depth .�. �- ............... � Capacity . `_�_ O: ©__- Type __.__--�__Compartments __ Distance to nearest: Well ------- ...........Foundation .......... Prop. Line .... -s...----------- LEACHING LINE (t� No. of Lines ......J Length of each line-..:'-..-. `` __. _ . �....... Total Length __._tP_q------------- ._ 'D' Box .__^.-._. Type Filter Material _..-,p.,_--Depth Filter Material..��7_.��__________________/..-..----.- Distance to nearest: Well Foundation D '. Property Line _..$------------ ___ [}� Depth ----- 1_jO._........ Daa�r�ter \_x^..�.�._ Number __ ....../....... ...... Rock Filled Yes Ik No i❑ Water Table Depth--------------------_�.....- .......Rock Size __--�-�'� X.3 Distance to nearest: Well ........ .------ Foundation _._1_O.----------- Prop. Line ._...__.-.__--- REPAIR/ADDITION (Prev. Sanitation Permit # .... _ ................. Date ----------------------------------) SepticTank (Specify Requirements) ............. -'-------------------------•------ ------------_--------------------------------------------------------------- -•-•---- Disposal Field (Specify Requirements) -------------------------------------------- ------------- ------------------------------------ ------------ ---------••---•------------------- (Draw existing and required addition on reverse side) I 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: "1 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 War"n's Compensation laws of California." Signed . --------- •- Owner By .............. 1 y Title - ....__.._. (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- --------------------------------------------------------- DATE ---f %3 ?----------- BUILDING PERMIT ISSUED ................... ------------ .-DATE ........................................... ADDITIONAL COMMENTS ------------------------------------ ----------------•-_------•--_--•--------- ..--•...............----...-•----•-•--•--•---......--•----• ----- ---•-----._...........---•-•-----•----......--•--•---...------••-•--•------- --------------------•-------- ------ --.............. .---•••-•-•••------------------------------- ........-----------.-- Final Inspection by:........-....---••-----------------•--------------•-•-••-----------------------•----Date/-.;-- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M