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FOR OFFICE APPLICATION FOR SANITATION PERMIT .......`...................... .... Permit No. .� (Complete in Triplicate) • �...._...-•-•............----------------------- Date Issued -?•- -- - .............. This Permit Expires 1 Year From Date Issued �7 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 Co my Ordinance No. 5449 and existing Rules and Regulations: JOB ADDRESS/LOC TT1 __ - - ------- ' �` ---------CENSUS TRACT .......�....._..._.. Owner's Name / --------------•••-. one --•--. ...Q � _City it -----•-- ----- _--•-•------•- Address --- - . 0 Contractor's Name _.- ._-_ 't=..License#��' yphone •._.•...------- ----_ - Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court ❑ Motel ❑Other------• -----------•---•--------- Number of living units:._..-I---- Number of bedrooms _-3---Garbage Grinder ._......... Lot Size -------_------- .__.____-_--•--_----- Water Supply- Public System and name ...................... -----------------_----_ --------------•-•--••-----------•-----------••------ Private [A Character of soil to a depth of 3 feet: Sand❑ Slit❑ 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,[! J� Size_--•--.--___ Liquid Depth -------_- PACKAGE TREATMENT [ ] SEPTIC TANK ] ------------- CaPacitY -------------------- Type ....-•------....._.. Mate►tai...................... No. Compartments ..........---------- Foundation ---- --•--- ---• Prop. Line-_----------------- Distance to nearest: Well -------_-_..............-....--_. - V Length of each line------------- _ Total Length LEACHING LINE [ ] No. of Lines '"-� ..De th Filter Material - . 'D' Box ..__..------ Type Filter Material P •--" Pro Line -----•-_.-----.-•----- _ Foundation ...-------------------- PAY Distance to nearest: Well .....................•- - --- Diameter ..------ Number _..------- ------ Rode Filled Yes ❑ No ❑ SEEPAGE PIT [ J Pt "'_-' Depth -- -- -- Water Table Depth .................•----- __---------------Rock Size ----------------------- ---- - Distance to nearest: Well ----------------------------------------Foundation Prop. Lim REPAIR/ADDITION(Prev. Sanitation Permit _„___ Date -------.-.___._._.._-._....__1 Septic Tank (Specify Requirements) ------------•--- -•---- ___.._---- . -_. -�---r- ..... .......------C--- Disposal field (Specify Requirements) "- - -" ••- ..__.... S .. -- X .................. 8........ --- - ------- -- - ... (Draw existing and required dditi on erse side) 1 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 DisMct. Home owner or licen- sed agents signature certifies the following: any person in such manner "I certify that in the performance of the work for which this permit is issued, i shalt not employ as to become subiect to Workman's Compensation laws of California." Signed - - -- ----•-- Owner itis -. •.�._ ---- -------- - - y By ---------__- ------------(i •-- ------ f cow owned FOR DEPARTMENT USE ONLY -- DATE --1-�:Y'-?-------------------- APPLICATION ACCEPTED BY ...� -- .... . DATE _----------. ---•----•--•--- BUILDING PERMIT ISSUED --------- _-----------•-------------- - - ---------•--- ..._ -••--•--------•---•--•----•--- ADDITIONAL COMMENTS ---------•-- _.._ - --•-•--•-•.._..--•--.-...._-_..----• ............. _ - - ------------- -- Final Inspection by: ... - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M - --