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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ..................... ..............................I.............I............ This Permit Expires 1 Year From Date Issued Date Issued _.:3-V_ 76 Application is hereby made to the San Joaquin Local Health District for a permit to construct and instoll the work herein described. This application is made in compliance with/County Ordinance No. 549 and existing Rules and Regulations. JOB ADDRESS/LOCATION - -_. . !� , _ :-� 'r� ..h .__....._...................CENSUS TRACE ....................... . Owner's Name ....�J ....1... ......... .................•--•----•-•----------------------•---•----- ...............Phone ........:........................... f Address .............. ...._.._.._ ...---- --.._..._._._...-•----- ----......-•--- ---- -•._. City .. -------..._....................................•....................... Contractor's Name -_._._ ... _..._.. :.....License # fZvUje� -.... Phone .............................. Installation will serve: Residence partment House-[:) Commercial❑Trailer Court 0 Motel ❑Other ----- Number of living units:...- ...... Number of bedrooms ___3....Garbage Grinder -._.-__.__.- tot Size ............................................ Water Supply: Public System and name ......................................---------------------.............................................:..._.__Private Q~ Character of sol I to a depth of 3 feet: Sand❑ ilt❑ Clay ❑ Peat F] Sandy Loam ❑ Clay Loam C].. . - 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 [ ] SEPTIC TANK f ] Size............................. ---_----------- Liquid Depth .................... Capacity ------- Type ---- ............_-- p Material......_-- *. No. 'Compartments Ly Distance ito nearest: Well ..........................:.........Foundation ...................... Prop. Line ...................... 6 LEACHING LINE [ J No. of bnes:--------------------------------- Length of,eadh line.----.--..._._-------....... Total Length ............................ � 1 'D' Box ..____....._•Typee-Fil et r M6- r;dI'...... Fou ........ .........Depth Filter Material ........................ Property Line _..... . 1 Distance to nearest: Wel! ........................ Foundation SEEPAGE PIT [ ) Depth Diameter ................. Number ............................ Rock Filled Yes '[j No i❑ r Water Table Depth ....Rock Size Distance to nearest: Well........................................Foundation.................... Prop. Line ....................... REPAIR/ADDITION(Prev. Sanitation Permit qIE .................--------------•............ Date ..........................•....... Septic Tank (Specify Requirements) .......................... _..---•••----------------•-----`---------------------........_............------------------- Disposal Field (Specify Requirements) - ` _ - �-.t r------------- ..__ .-,r .--- JV -------- -� ... .. - ------`� ------� --- --- ,'� -`-r' ----- -••---------------------------------------_._ ------- -------------------------•-------•------------------------------------------------ ------------------------ ----• .- (Draw existing and required addition on reverse side) I hereby certify that 1 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 become subject to Workman's Compensation laws of California." Signed -------------------••----------------------•-•-•-- -•-------------- - --- •--------- Owner By -•....................................•----------- :. ,...._. -- Title ..,(�dFe. i�:......._.. `) (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .......C.!...... Q. DATE �.... BUILDING PERMIT ISSUED ...... - .DATE _................................ ADDITIONAL COMMENTS ..................... ..........•...-..........................................• .................... .............................................. ---------......._.._.......... ....................... ---- --- ----- --• Ina Inspection by: .. �.... -•--•---•.....................................•-•-,.......••••-•Date .... . � JOAQUIN LOCAL HEALTH DISTRICT ' E. H. 13 241-'68 Rev. 5M _- 7/723 M }