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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ........... Permit Nod .:.....�... . ...... ............. I (Complete in Triplicate) ......... `... ....... This Permit Expires 1 Year From Date Issued Date Issued 15 .,f-? 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/LOCATI N .. ......... �•-••CENSUS TRACT ...... OwnerOwner's 's Name ................Phone .. .... Address ...................... ....... ............. City ....S7Dck�!`ON..................... ....................... Contractor's Name - ................License #,PT5.`4y3...-- Phone ..4 :7- Installation will serve: Residence[Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑-Other ............................ ` Garbage Grinder lot 5 . , 35=.�- •••-;--•••- Number of living units:.......... Number of bedrooms .3..._... g ---••------- Water Supply: Public System and ...... .=Ptivbte ❑ Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy�Loom-t Cloy-Loom:, Hardpan❑ Adobe ❑ Fill Material ............Ifi osj type............................. (Plot plan, showing size of lot, location of system in* relcopn to wells buildings, etc. must_be. placed on reverse side.) NEW INSTALLATION: (No septic tank or seepagei pit permitted if pubic sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK-f ] Size.........� ,._.............................. Liquid Depth .......................... _ _ ents ............... Capacity . TYP �atenai.._..... No. Com artm ..... Distance to nearest: Well .......Foundation ... Prop. Line LEACHING LINE [ J No. of lines . . iengtlr of each line............................. Total length ............................ 'D' Box ............ Type Filter'Material ....................Depth Filter Material .....................------•- Distance to nearest: Well ....... foundation Property Line ........................ Depth SEEPAGE PIT [ J :. . Diameter ................ Number ............................ Rock Filled Yes ❑ No (� Water Table Depth ..............................Rock Size ._......---•--..............._.. P Hv Distance to nearest: Well ....Jouodc tion .................... Prop. Line .....................p .....- ;Sep;tVico;n ;Spe�cify eV. Sanitation Permit# ............................................. Date ..................._..............) y ;Requirements) ................... .......................................................................................... •-•.................... Disposal Field (Specify Requirements) f 2.'?...��' '�"�'�"� �'��` .. W .................................•. .....................................---•••.............-• -- ...--•••••---•.............-- . ........ .... •. ... . . . ....... ..... ...._......._......................... ..............----------...--.. `::::.....:. .... (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 an'd-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 tyjs permit is issued, I shall not employ any person in such manner as to becom��:ubiect to Yorkman's Compensation laws of Callfornia." Signed ....... ..X... -.., .... ......................................... — ..................... Title . .:............,......................................... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ................ DATE ......... ... -•�� •........ BUILDING PERMIT ISSUED ....... ................... ..... ....... .......... ...: .... .... ..................... DAT ..... ...... ADDITIONAL COMMENTS ..$�. P'..?.` .. 2 . .` .. -� .r.................................................... ........ ........... ..............•-------•--......... .......................•...•.... . .................................._..........................•-•................................................... ........................................... ....-.• .................................-•-.........................•........................................Date ... 2 __ ..... .... .... - Final Inspection by: ..... ' ..r................................,.........-•---................. T- SAN JOAQUIN LOCAL HEALTH DISTRICT E_ H.13 24 1.'68 Rev. 5M 7/72 3 M