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a FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ..................................................... ........................ ..................•--.. (Complete in Triplicate) Permit No. .....7..... .._...... ............................................ 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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulationst JOB ADDRESS/LOCATIO .l�_�. .. . ............... -.................,....................CENSUS TRACT .......................... Owner's Name .. A.. ... _ ...__.... - -----. ....Phone ..._... �.._.._............._ Address .............. '�' .� ....._... ..... ....City r................................ ` .. Contractor's Name .._.... Phone l ...... ..._. ....... �._........-_.._.License �d _3 :.. Installation will serve: Residence®Apartment House 0 Commercial OTrailer Court 0 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❑ -Silt 0 Clay Peat❑ Sandy Loam 0 ' Clay Loam Q Hardpan❑ Adobe❑ HN 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 [ J SEPTIC TANK( Size............................ Liquid Liquid Depth ........ Capacity..................... Type -......!._,....... Material...................... No. Compartment: ................... Distance to neorests Well ....................................Foundation ...................... Prop. Line .....................5 EACHING LINE [ ] No. of'tinea ........................ Length of each line............................ Total Length ............. 'D• Box ........... Type Filter Material .. .a::.....Depth Filter Material ...................................... Distance to nearests Well .......:.......:....... Foundation ... Property Line ............... SEEPAGE PIT [ ] Depth Diameter .................Number ._......._..:....-•-----.... Rode Filled Yes ❑ No Q To WaterTable Depth .................................».............Rock Size................................. Distance to nearest: Well ...................... .... —Foundation .................... Prop. Line ........ _.. .� REPAIR/ADDITION(Prov. Sanitation Permit#............................................. Date .......................,_........ ) O Septic Tank (Specify Requirements) .................------------------------ --- --_------•- ................._................................. ................ Disposal Field Specify Requirements) .._ .�S`cc�%•0 .. _..................... �..e ¢.. ........ ......................................................... exist ................................ ............................................ (Draw .i ing 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. Herne owner or licen- sed agents signature certifies the following: enon In such manner "1 certify that in the performance of the work for which this permit is issued, I shall not employ any p as to become subject to Workman's Componsuflon laws of Californio," Signed Owner r j By .............................................. . aide _.. ..-..... _..-.---..__._....:..............._... ._.. (if other than own r FOR DEPARTMENT USE ONLY 7.... W lt. APPLICATION ACCEPTED BY ...................................... ATE .. .J-.Z. _...... BUILDING PERMIT ISSUED ........w..................D. ... . ........_.....••--•-- ...._ _�_-........_...,MTE: ...... ? . ................ _4DDITiONAt„COMMENTS................:..... ........................:............•�... _......... .....--........_................................. - -•....: _..... .:..._�- _ - %�-....:...... ............. ... . .......e ............ .._....._....._._.........._._...Date �....r,�.'F'�l' .....�..... - _. .................... ... Final Inspection bys .. ' SAN JOAQUIN LOCAL HEALTH DISTRICT ./- - - 7/72 3 M E_ 14.13 24 1.-68 Rev. 5M_