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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i 7S-- ...................... ................................. (Completo in Triplicate) Permit No. ..................... ............... .......... ............ 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: r � I .�s __. .'. _,.JOB ADDRESS/LOCATI ... I................. _a ._.,........:......CENSUS T-RAC.T. ....... ... Owner's Name ....... - ' ^ _phone 47... _ .._.. CityAddress ..................... --- •- ..... .................. Contractor's Name ------ ...... - ...License # YPione . ........_....:......-..- .. Installation will serve: Residence❑Apartment House f] Comme 'al :❑Trailer Court ,❑ A 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 p ❑ ilt❑ Clay ❑ Peat❑ Sandy Loam ['] Clay Loam ❑ ! . p ❑ l I Hard an Adobe Fill Material ......_._.._ if yes,type _.._...--------------------- r (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 seep a pit permitted if public sewer is available within 204 #set,) PACKAGE TREATMENT [ � `r f [ ] SEPTIC TANK Site. �•_..:,�-�--,r�._+�.---...._. Liquid Depth ---�--•................� !. Type s_ Capacity . ..... .0 Materia . .....�.,....... No. Compartments .-� Distance •to near st: Well ......,�_Q......................•Foundation ....../.!e--------- Prop. Line ....af.. LEACHING LINE [ ] No. of Lines _......?---_•-"__..`. Length of each line.------ 'lJ...�._•--_--- Total Length ............. 'D' Box .4...::_ Type Filter Material ___.__ Depth Filter Material oil r. ....................... Distance to nearest: Well �__�_--. Foundation 0� ......._ ._. ... �....------•. Property Line ...X .." ..X ..•----•--....t� SEEPAGE PIT [ depth ...P�r.S..j.... .Diameter -„�.., Number ..._- ._....-_.. Rock Filled Yes No .... Water Table Depth ` I � ...Rock Size Distance to nearest: Well .... prop. Line ------- -�.......................Foundation ....,�.V......_. . ..._--------•-•---- REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................... Septic Tank (Specify Requirements) , Disposal Field (Specify Requirements) ............ ............ ................,--.---....................................... ...._ -------------._- ._ _........... (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. Nome owner or Iicen- 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 Co ensation laws of California.” Signed ............ ...... Owner By ....................................... -,..---... _.� . Title .. _.. .. 1__,__ . (If other than owns --�--�--�'- �• • .......••'•••••- FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY ........... - -•------ ----------- ...............................I............_ . DATE ...._.TE BUILDING PERMIT ISSUED ADQITI N L COM B -`Y�-� .. ,�. .. _ _... ------------------ - ----.-..._.. A ... '.. - �.�Y �.�..... � :- _ �. : �.-_ ................... ._. . . .............-........................I._----- __ --•-•-. Final Inspection by: ----=-------------- !� ...._.._...•-•--.... . .• �` .j ?� --------- --............................ •----........ .........-..._...........--• . ••----.Date -� ---. ..........-----•--- SAN JOAQUIN LOCAL' HEALTH DISTRICT 1.'68 Rev, 5M 171 I-V