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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT +. �.. :... ........... . (Complete in Triplicate), Permit No. �s. �:: :............. .............. Date Issued K +� This Permit Expires 1 Year from Date Issued Applicotion.is hereby made to the San Joaquin local Health bistric#'for a permit to construct and install the work herein described. This-application is made in compliance with County Ordinance No.;5�49 and existing Rules and Regulations: r a JOB ADDRESS/LOCATI 11 L�..I. -- ---- _.. ?. ---- ---. .. .......... CENSUS TRACT Owner's Name ......:...Phone . � �• ��---------- Owner's / Address f ------........_._.. ��- � _�....... ... .. ..... 4 City Contractor's Name - - --------------- =---••--- -• -• ---•- --.�.....:5._..__�.�-!....:..---...License ��..-:-.�._.�..._ Phone - Installation will serve: Residence Apartment-House f] Commercial ]Trailer Court Motel f]Other............ ............................... Number of living Units:...... _.._ Number of bedrooms _-_-..Garbage Grinder ........ ._ Lot Size -..-•y �_._? j -------------- Water Supply Public System and name ................. ....................................-..-----------& Private(]. Character of soil to a depth of 3 feet: ` 'Sand 0 , Silt❑ Clay ❑, Peat f] Sandy l.dam ❑ Clay Loam Q i Hardpan❑ Adobe ,-Flll Material ............ If yes,type............... ............ (Plot plan, showing size of lot, iocationiof system.-in relation to wells, buildings, etc. must be placed on reverse side.)\ ! NEW INSTALLATION: (No.iseptic tank.or seepage pit permitted if public sewer.is available within 240 feet,) PACKAGE TREATMENT f 3 SEPTIC TANK I ]_ Size............:................................... Liquid Depth .............-...... ._._ Capacity Type Materia)---------------------- No. Compartments ---------- ........... to nearest: Well --. Foundation Prop. Line :.. ......... --•-.---- ................. LEACHING LINE [ J No. of Lines __............... ength of each line............................ Total length -_----..----_----.--------- ' �. D' Box Type f,i(ter Material'`.:n: :.............Depth .Filter Material �-.Disicince_to. nearest: Well ....1------...............foundation-_.._--------_-.-....-Property Line ........................ SEEPAGE PIT [ j Depth .................... Diameter ................ Number ........._.. ............... Rock Filled Yes J] No Water Fable Depth -•----------------------••----- ................Rock Size ................................ Distance to nearest: Well ...•....................................foundation .....:_. ----------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Per Jt 5iE -,.•--•--•• ...... Date .'.................:.:*_........._j Septic Tank (Specify Requirements) . ... . .. ....... ... ....a!a'1�... Disposal Field (Specify Requirements) '' ----•------•-•---•---• --------------------------------------------- ....------------------- --•-------•--------------------•---------........ ...... (Draw existipg_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. Home owner or linen. 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 (If other n owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------------- ....... DATE . ." -7._'7C_-.------ BUILDING PERMIT ISSUED -----------------•-------•- .................. ...............................-DATE . . ----------------•------------._.... ADDITIONALCOMMENTS ---:........................ ....... ... ..............,---------------........................... ---------------------------------- .................... Final Inspection b ---..Date -----•--•••---- i EH 13 2L 1-68 N !O UIN LOCAL HEALTH DISTRICT 8/7h. 3M f