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4 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT l ...................................................... , Permit No. ...`r.5.�.-J:3_•---= I (Complete in Triplicate) ... . This Permit Expires 1 Year From nate 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 to compliance with County Ordinance No. 549 and existing Rules and Regulations: 1931 N � ej ..................CENSUS TRACT ..........:.... ..__.... JOB ADDRESS/LOCATION .._ ._.....�....... .... .........._......_._........ . ... 1..-__._ �... .....................................Phone Owner's Name . ............. Address _..-._ /. ...1 .. _ . .....,...2 .. ........... City ._... 1 `. .......................................... r J Contractor's Name ------- .- ----- ------• -•• ...... _ :✓.. .......... .....License ...... Phone ..............•.---. ......... Installation will-serve- Residence Apartment House-0 Commercial:❑Trailer Court ❑ rr Motel ❑Other ----------- ......................... ----•• Number of living units... ---- Number of bedrooms --p ....Garbage Grinder ............ tot Size _.................. ••.. - -------•--•--•.• Water Supply: Public System and name -•----- ------ --•- • - --------.................•------- ..----------••. ----------- - Private [ Character of soil to a depth of 3 feet: Sand 0 Silt ElClay [3 Peat El Sandy Loam {� Clay Loam ❑ �I Hardpan E] Adobe E] Fill Material ............ If yes,type ------------- ------------- 1 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) I $ PACKAGE TREATMENT [ ) SEPTIC TANK 1.1 --------------------------•-••-- - Liquid Depth ..__................ � Capacity Type Material---------------------- No. Compartments -,._............-.. -� i F Distance to (nearest: Well ................•_• ................Foundation ...................... Prop. Line ......................00 LEACHING LINE [ ] No. of.,tines, ... ............... Length of each line._.-....____-__-_.. ---.____ Total Length __.._..._._,.._..........._.� I ? 'D' Box ....... _:._ Type.Filter-Material -----::..............Depth Filter Material ............................................ Distance to nearest: Well .................. Foundation -----................... Property Line ........................ SEEPAGE PIT J ] Depth Diameter ................ Number ........_................... Rock Filled Yes ❑ No C3 Water Depth -------Table� Rock Size ............................ t ..................Foundation -. -_ Prop. Line ..-•--•------•-• Distance to nearest: Well ....--------••------- +� REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------•-•••.................. Date ..................................) I Septic Tank (Specify Requirements) ......................... ....... ........ -----••-- -•---- ---•:................... ._. ........_...... Disposal 'Id-(Specify Require ants) --- `�" Vii► �Qc�.• ............ ...................... ----......-----•--...... ----------............................... ._..--- --....------------ ................................. ................. (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. Ham* 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 ............................................... :,_...._....... .--- Title .................... ...• (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _ _ ....--------•••-••--- DATE .. .'. ... _ ....... ..._. BUILDING PERMIT ISSUED ..... ..-•-••........_ -............DATE ...................................... ADDITIONAL COMMENTS : .. --•-•-- .......................................................... ` ......................... ........................................ .._......._. = atef" Final Inspection by: .. D SAN JOAQUIN LOCAL HEALTH DISTRICT _ W 7/72 3 M r �. 1 1 2G ti ��e 6_.- tAA _