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FOR OFFICE USE. �.�: 6 APPLICATION FOR SANITATION PERMIT 7 7—� ..................ry_................. ............ . ICompleto in Triplicate) t! PermitNo. ................•---• 11, d1i ......................... This Permit Expires I Year From Date Issued Rate 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 �-�E/��.._. / � ... .... .. . TRACT ......... ................ Owner's Nome - _...../,�\ / ....................:................_....................Phone .,._... .... .__ ------. city ., <1� .. --------- Address Contractor's Name ..... .....£-t ._ _F:�x__ _c�,� ,, �?...License s? /7 . Phone Installation will serve: Residence Apartment House Commercial ❑Trailer Court 0 Mote! Other............................... • •.... Number of living units---j------ Number of bedrooms ....I......Garbage nder ............ Lot Size �� ... _...__...... Water Supply. Public System and name ..Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay loam Cl 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 slde.&3 NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) r� PACKAGE TREATMENT { ] SEPTIC TANtCij ] Size----_- ... . ..........::... Liquid Depth ..... ._....... Capacity _� p.___-- Type - - Material.. p -.. No. Com ar#ments r / Distance to nearest: Well _..__. . .. ...Foundation .......... Prop. Line --....4........ LEACHING LINE { j No. of Lines .............. --------- Length of each line............................ Total Length .......................... 'D' Box ............ Type Filter Material ....................Depth Filter Material .......................................... Distance to nearest: Well ........................ foundation .................... Property Line .......-----------••-- SEEPAGE PIT ( } Depth -------------- Diameter ......:......... Number ................... Rock Filled Yes ❑ No Water Table Depth ..----•.................. .........•. a-•---••... ......Rock Size ............................. Distance to nearest: Well ..........:.............................Foundation .............. Prop. Line ---..---..------.-..- REPAIR/ADDITION(Prev. Sanitation Permit# .....--.._ . Date .................................. ) Septic Tank (Specify Requirements) ...... --- --------- •-----••-•----- ------•---------------------- -- ,r.,� r.............. Disposal Field (Specify Ito uirements) --- .... •�. ---- -- -------- - s� - ... ---......_ ... ---------------------- - ---------------------------- ---------------------•----.--•---------------------- ....................................................................................... (Draw existing and required addition on reverse side) I hereby certify that 1 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,Dlstrict. Home owner or licen- sed agents signature certifies the following: "I certify that i the performance of the work for which this permit is issued, I shall not employ any person in such manner as to becom su iect to Wo kman' Com ensation laws of California." Signed ------- -- ----- ----• � Owner '~ By -------------------------- -- --.---- ---- - ------ •- ---- --------------- -Title (if o er t owner) fO PARTMENT USE ONLY APPLICATION ACCEPTED B ------ lct.P--[�-- -- -----------._.... DATE _. BUILDING PERMIT ISSUED --------------- -----------------•---- ------------------ ...... ------------------..................DATE /- ------------------------- ADDITIONAL COMMENTS --------------- ----•--------------- -------------- ---------------•--- ••-- - . Final Inspection by: .. . • -•---- ....••. -.._...-•----------------------•--•-------•----------._..._..•-•----••-----------.-.Date - _ -- -.-...------.._. .... -•.................... El 13 24 1-68 Rev. 5I SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M