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FOR OFFICE: USE: ' APPLICATION FOR SANITATION PERMIT ¢ ........................ ........ Permit No. . ... .75�`{Complete in Triplicate) ......................................................... This Permit Expires 1 Year From Date Issued Rate Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. ._ yy, JOB ADDRESS/LOCATION ,.. ✓- CENSUS TRACT ...... Owner's Name :..... Phone Address ` _ --• ....... City +• ' d , ................... .................. Contractor's Nome _. ��Ps?'--------- ---•-• :............ _License #a i�/.+�'"r: r� Phone Installation will serve- Residence Apartment House-E) Commercial ❑Trailer Gowt- SI / Motel ❑Other ............... ......................... .. Number of living units:___!-..... Number of bedrooms .._...Garbage Grinder,ejP`Q--- Lot Size •-••••••-•-••------•- Wafer Suppiy: Public System and name ................................................................"..................................._.._.......Private,$ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe10Fill 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK 1 J size............................................ ... Liquid Depth _......................... Capacity .................... Type .................... Material-----------........... No. Compartments ......................�i Distance to nearest: Well ..__••..--•----•....................Foundation .-__..........._...... Prop. Line ...................... LEACHING LINE ( j No. of Lines --------------------_-- Length of each line............................. Total Lehgth _._..... ............... W 'D' Box ............ Type Filter Material ....................Depth Filter Material ..........•................................. Distance to nearest: Well ..............I......... Foundation ................... Property Line ........................ . SEEPAGE PIT [ ) Depth -------------------- Diameter ................ Number ..__.................... ... Rock Filled Yes ❑ No ❑ • Water Table Depth it....................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ------- ..................... Septic Tank (Specify Requirements) -------------- ` ...... ........ w......_.............�..... - . D;s osal Field (Specify Requirements) -. ...1, ..., lL � ` > 54_� . . ..................•-----.--------------.... -------------------- - (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. dome owner or licen- 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 ........__.................... . ..... . • ........`............................ Tlt�e �t---------........_...------......., (if othe an owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .....�._ ............................. DATE -- - - ..... ----•---- ..... BUILDING PERMIT ISSUED .......DATE ........................................... ADDITIONALCOMMENTS ............................................................. ----.................................... ---------------------............................... .........................••--------••-----_........._..... _._._.-- . ------..........------------....._....... ............. •- ----• -- ............................. ----• ---- --- .. Final Inspection by: .•......--•------Date . .......,.. ...... �~` SAN JOAQUIN LO HEALTH DISTRICT E. H.3-3 24 1.'68 Rev. 5M �. _ ._.— _ 7/72 3 X