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U.JL: APPLICATION FOR SANITATION PERMIT ---•----•--------- ..........-- No. (Complete in Triplicate) Permit .................... •..............................•------•----.... ......... .••................................................... This Permit Expires i Year From Date Issued Date Issued .. :. s 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 Ordinance No. 549 and existing Rules and Regulotionsc JOB ADDRESS/LOCATIO .......�.I.uS._o?,,c .. ... ---'-- Jn.. .. ......................CENSUS INV. , CT .......................... Owner's Name ............. C .�...........................................................Phon ./...�D..... Address n.. ..........�.��.� �' - - ---� . ^ � ��................. City ...�-�.0 . . �.,, � ._............__...._ Contractor's Name . �`�/ :..._.. .....................License # 1.. /__17/.. Phone �.J Js.� Installation will serve: Residence ❑Apartment House f] Commercial ❑Traller Court Motel ❑Other----------•--------•-----•----------------- J r� Number of living units:-........... Number of bedrooms ............Garbage Grinder ............ Lot Size ..!-.1=��—ll..n� ��........... Water Supply: Public System and name ............... . ...................................................Private Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat❑ Sandy Loam & Clay Loam ❑ Hardpan ❑ Adobe 0 Fill Materlal ............ 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[ ] Size................................................ Liquid Depth ..........................� Capacity -------- ------ Type .................... Material---................... No. Compartments ......................� ----- - Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... t LEACHING LINE [ J No. of lines ........................ Length of each line............................ Total Length ............................ k 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ ] Depth ___---------------- Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑ WaterTable Depth ................................................Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# ........I.................................. Date .................... Septic Tank (Specify Requirements) ......� ...I......... ..�...., .� .�. �T.� t e ............. Disposal Field (Specify Requirements) .........•-•------------------------------------------------•------....................---•-.----.6 ----------- ------------------------------------ ---- ---........................-..............................................................-................................................. ---------------------------------------- -- ------------ --- -------- ------....------------•...------..............---------...........----------------.................---.......... (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. 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 ........................................................................ (If other than owner) �41-Olt D PARTMENT USE ON-Ly APPLICATION ACCEPTED BY .. ..... DATE BUILDING PERMIT ISSUED ... ......................................... ...... . .............. ... ........................DATE .. - -.... ADDITIONAL COMMENTS ....I3 ./ ;:IJ4 v... f� _ .......................................... .1.......- �..c �X .. .... .. 'f . .....��. :.:::::::::::..:::::::::::..::::::::: ------------------------------ --- -- .............................. .--- .............. . . ............. .. Final Inspection by - - ----.. ... /. .. ...... . Date -. ......" l '-- J... ... EH 13 21 1-68 &v. 5m }' SAN JOAQUIN OCAL HEALTH DIST ICT 8/7h �M