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FOR OFFICE USE: d 5 PPLICATION FOR SANITATION PERMIT Po. --------- �' c Permit N `f�- 5' J (Complete in Triplicate) I- (-.--- ------------ --------------- 4-2-1-0___________________-_- 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 existing Rules and Regulations: JOB ADDRESS/LOCA�ON . ,- ' ------9- - 7 --------------�--------CENSUS TRACT ----------- Owner's Name ° Phone- 4� �-�---- r /1 7Z_ Address ----------------------------------- City ------- �— 2 --------------------------------- ---------------- ---------- ---------- -- -------------License # Phone _�- ---Contractor's Name l_ ✓ v Installation will serve: Residence ❑Apartment House❑ Commercial ❑ ailer Court !❑ Motel ❑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 ❑ 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 [ I SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth __________________________ Capacity -------------------- Type ------------------- Material-------------------- No. Compartments ---------------------- k Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ____._--__.___---_____ LEACHING LINE [ ] No. of Lines ________________________ Length of each line--------------------- ------ Total Length ---------------------------- Q�l '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 i❑ Water Table Depth .----------------------------------------------Rock Size ------ ---- -------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line __--.._-__.___-______ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------- __ ____ ____ __ -_-_ _ __. ... __ Dispo al Field (S)ecify Requirements) G �__,�__ �' _ - -__ (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 becoyne subject to Workm `'s Compensation laws of California." Signed - =- < e' ''��, -iia- -= � ---- Owner By ------------------------------------------ ----------- ------ Title -------- - ----- ----------------------------- ---------- (If other than owner) ARTMENT USE ONLY APPLICATION ACCEPTED BY ------- -� - -------------------------------------------------. DATE ---��~�a� ------------ BUILDING PERMIT ISSUED -- ----- j =--- -------- = ------------------------------------------------- ---DATE ------------- -------- ADDITIONALCOM - --------------------------------------------------------------------- ------------------------------- - ---------I -�TSI ----- +_ ---- ------- --------- - - ----- ----------------------- --------------- - ------------------------------------------ ------ - - -------- ----------------- ___----------------------------------------------------------- /'n �cN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M