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FOR OFFICE USE: V APPLICATION FOR SANITATION PERMIT ........ .. Permit No. ..74/--7,�_ (Complete€n Triplicate} ................. ..............................I....._. ie ......................•--_--............................ This Permit Expires 11 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 rdinance No. 549 and existing Rules and Regulations.- JOB egulations:JOB ADDRESS/LOCATION .....---...Xis—... . . . . • ....... --.......--..............................CENSUS TRACT .......................... Owner's Name ............ .. .--yy.,,.._..._.._... _ ........ ......................_._............... Phone*vx ...a.. 0 Address ---------1;::::Z ------- -- l ._._ . .. ....--•............... City .. ...... -------•----••- Contractor's Name ...... _.... --- .......................................License # --•--..................... Phone .............................. Installation will serve: ResidenceXApartment House Q Commercial ❑Trailer Court Q Motel ❑Other -----------------------•••-••-•--- ...... Number of living units:... ... Number of be ooms .. Garbage i of Size . .;, .. . .. ................... Water Supply: Public System and name....... :. _....................................................Private[, Character of soil to a depth of 3 feet: Sand 0 Silt[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ Hardpan ❑ Adob>k Fill Material ......._.... If yes,type-------------------------- -- (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit<permifted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ]Z4X1Z ize................................................ Liquid Depth ------ .............. Capacity -------------------- Type .................... Material.---..---- ..._..__.- No. Compartments Distance to nearest: Well .............................. .....Foundation ---------------------- Prop. Line ...................-.. LEACHING LINE No. of Lines ........ __ . Length of each 'ne------- Total Len th .............. D' Box .- __-- Type Filter Material . Depth Filter Material y -i----ee -•------------------------------ Distance to nearest: Well ....... Foundation ......... Property Line ............ eel SEEPAGE PIT Depth -447c.S.7..... Diameter .%...V.:.••.. Number ........ ................ Rock Filled Yes No Q s yy er Water Table Depth Rock Size .oG Distance to nearest: Well Arzo. .....Foundation .Z �_..__ Prop. Line ..%177r REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................._) Septic Tank (Specify Requirements) ........................... - - - -------- ---- ® ........ _.... .. ............. Disposal Field (Specify Requirements -------- ---- ---- --- -•- �` A. ----•---------------------------------- - -------------------------•- -•----- ---------------------------------------------•-•----........................_.........._..... (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. Horne 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." ��' �"- Owner Signed ..-. .. .. _�'��............. BY ........................... ...................... ----------------- Title (If other than owner) FOR DEP RTMENT USE ONLY r APPLICATION ACCEPTED BY ..... ............................................... DATE <(. .:- 1+� ................. BUILDINGPERMIT ISSUED --------------- ------- .....................-..........................................................DATE ._......... ............................ ADDITIONAL COMMENTS .......................•-•--...----•----..._........:........................... ............................................ ....................................... .. .... .... .. .. ...........................................................---•--......••------•..__....... ..-_-/.......------•••._-.......-----•................._._.._..__................._.._............... r:.. ..............t_ �.... �..._....... ----- Final Inspection by: n'. .......Date .... �) .�. !... �JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241-'68 Rev. 5M 7/72 3 M