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FOR OFFICE USE: APPLICATIOR--FOR SANITATION PERMIT ---------------------- (Complete in Triplicate) Permit No. a.r --------------------------------------------------- ----- ---------------------------------__------------------- This Permit Expires 1 Year From Date Issued 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 ules and Re ulations: JOB ADDRESS/LOC/ ON __ ___/__ __ _ �� _-- SUS TRACKCa ---- -- Owner's Nam- _- ---- ---- - --------Phone c _ -- --� Address .__ Cit -P-4 -----------�� ---- . _ -- -------- - - Contractor's Name ____ ______.License # aQ' f _ Phone _l_�___-�__�_� �� Installation will serve: Residence ,kApartment House❑ Commercial ❑Trailer Court i0 Motel ❑ Other -------------------------------------------- Number of living units:---_,--- Number of be ooms __r ____Garbage Grinder 14�V__ Lot Size __1 0-____-4` ` Water Supply: Public System and name ----- -.--------6J ----------------------------------------------Private ' Character of soil to a depth of 3 feet: Sand'❑ 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 seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] if'r� 7 Si e----------------------------------------------- Liquid Depth -------------------------- Capacity -------------------- Type -------------------- Material--------------------- No. Compartments Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- �> LEACHING LINE X No, of Lines _______ _/___________ Length of a ch line------- �__.________ Total Length --Total 'D' Box ____/____ Type Filter Material - ____Depth Filter Material __r __ �, Distance to nearest: Well ----ts�Q_--_____ Foundation ___/C�___r------ Property Line ----!7�____,_____ SEEPAGE PIT Afgr* Depth ____________________ Diameter ---------------- Number ________._________ ------- Rock Filled Yes ❑ No ,fl Water Table Depth -------- ---------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation __________________ Prop. Line _____________________ REPAIR/ADDITION(Prev. Sanitation Permit�# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) -------------- --------------------------------------------------------------------------.----------------------------- Disposal Field (Specify Requirements) ----- ------ - ---- �---------- -------------------------- ---- ------------------------ ----------------------------------- ---------------- -------------_—Z Z----------------------------------- ---------------- - - ----------------------- ------------- ------- ------------------------------------------------------------- -- - -------- --------- ----- (Draw - -- (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: "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 Warkman's Compensation laws of California." Signed ------ �-- - - Owner - - - ------------ ------------------ - ------------------------ - -- BY ------------- _ -- .R.------- u��------ Title --------- ------- - -------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----- DATE -------~� ------------ -rf� �1� - - - - -------------------------------------------- --------------- BUILDINGPERMIT ISSUED ------------------------------------------------------------ ------------------------------ --------------DATE -------------------------------------- ADDITIONAL COMMENTS ------------------------------- ---------------------------------------------- ----------------------- --------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ----------------------------------- ---------------------------------------------------------------------------------- -------------------- ---- Final Inspection by: -------- Date -----------�� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M 0� 5�