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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. _..�5-:�. ........... .....................I.......................... This Permit Expires I Year From Date Issued Date Issued .` - :•�S` 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCA N ,. ��_9.�0---- C( J........................................CENSUS TRACT Owner's Name ...... .._.�.F.. .................•---..... . . ._Phone Address ..........A �. - _..-............. ----•9.................. ......... City ...._..._ Contractor's Name .... � . ' - ,.....License # I .3 -_ Phone .... ................ Installation will serve; Residen a Apartment House Commercial ❑Trailer Court 0 Motel 0 Other ....................... Number of living units...--- Number of bedrooms -. ---•Garbage Grinder ............ Lot Size . . ........... Water Supply: Public System and name ................ . .... .. . . -------•-----------••------._._.------.._...•.-._.....-•------...._ Private �. Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay C1Peat❑ Sandy Loam lay 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 [ I SEPTIC TANK f ] Size..................... .......... Liquid Depth ..._....._ ........ Capacity ..-------.---------- ---- Material---------------------- No. Compartments Distance to nearest: Well ..................--- -- -•-•-•-----Foundation ----------------- Prop. Line .................. LEACHING LINE ( J No. of Lines . Length of each line---------------_--_------- Total Length 9 'D' Box ............ Type Filter Material ............. .. Depth Filter Materlol __.......--.._---•-..--•-•.................. Distance to nearest: Well ........................ Foundation _..-__...._...... ------ Property Line SEEPAGE PIT [ ) Depth ------------ ------- Diameter Number ------ ................... Rock Filled Yes ❑ No ❑ Water Table Depth Rock Size - Distance to nearest; Well ............... ..-.Foundation _--___- Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..----....-•-__. } ------ Septic Tank (Specify Requirements) .___.......... .............. Disposa" Field (Specify Requirements) .- � _ - ............ --01 . "----------- -- raw 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 far 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 ............f_ �er By ..... ........... ., }_�. -----...._...._.. Title...(0- - --- ---------------------------------- �e ---- ._............................. { an owner) F DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ......... BUILDING PERMIT ISSUED ------ ------................. ------. -••--•----•.....-----••----...._ ........ DATE .... 4 ADDITIONAL COMMENTS ........ ............. ....- -.-..------- - -----•---•------•------•------•......................-------•-••-------........._DATE .. ..----.,............. - . ..•---.... .... . ----------------••••-------•--•..........•---•••-•--... ............................................• ----.............. Final Inspection by: ....•••..............Dater+_....... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 13 24 1.'68 Rev. 5M