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Foi�yer� APPLICATION FOR SANITATION PERMIT Permit No. ...............`.. (Complete in Triplicate) ._..__._ - .......................................••• . p Date Issued .................. . ....-• ----_..... This Perritt Ex ires I Year front Date Issued Application is hereby made to the;San Joaquin Local Health District for a permit to construct and install the work herein 1 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION . . �1_.7C._.. .� ice._ CENSUS TRACT ............... ....... - .:......... P• j1`f ...........Phone ... .r/ 1✓...._. Owner's Name ...... .. ...... Address . .1�J" -y- /��. /��._..... . .... city [ Contractor's Name ..License # ........•--- Phone .............................. Installation will serve: Residence Apartment House f3 Commercial ❑Trailer Court Motel ❑Other _------_ ------•--• --•--•.............. Tom. Number of living units:....----- ... Number of bedrooms Garbage Grinder Lot Slze .... ..... Water Supply: Public System and name ------------- .........................................................................................Private 1 Character of soil to a depth of 3 feet: Sand❑ ilt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan M 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 _j NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) is Liquid Depth PACKAGE TREATMENT ( ] SEPTIC TANK ] Size---------------------•--....----.......... q p F. -- Capacity --------------• ---- Type --------•--•....---- Material...................... No.. Compartments .. Distance to nearest: Well ..Foundation ........ Prop. Line ............:....... Length Total Len th LEACHING LINE [ ] No. of Lines ---------------•------- g h of each line---....._............... g i . D' 13ox ---._..._.-. Type Filter Material -...................Depth .Filter Material ............................................ k �- Distance to nearest: Well ------- ---. Foundation ........................ Property Line ........................ I SEEPAGE PIT [ ] Depth ... Diameter .--._----.---. Number --------•- Rock Filled Yes ❑ Na [] WaterTable Depth ....----------------------------•-•-............Rock Size .............-.._............... i ....._ Distance to nearest.- Well ------------------------------•-----"-..Foundation .._..._.. .......... Prop. Line .... , REPAIR/ADDITION(Prev. Sanitation Permit# ..... ------ -- -- Date Septic Tank (Specify Requirements) -_--_----.........•------------•••---------- -.. ..-- ---- •-----•••. .••-- Disposal Field (Specify Requirements) .---- -•-• rte.`".... ��3`�. _'""""'"_.� � v ii ,r ... f1__1 ............................................- - --- I ............................................................ ------------------------- ---- •--------..�__.- ...... ..... ...._ . (Draw existing and required addition on reverse side) 1 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 Son Joaquin Local Health.Distric#. Home owner or licen- sed agents signature certifies the following: "I.certlfy that in titre performance of the wo k fo which this permit is issued, I shall not employ any person In such manner as to become su to Workman's Co ns on aws of California." Signed ------ •--•-----•-•-----...---- Owner r -------- - - - ----- --- ----- --- --- ---------•--------•---------------•- ...-----• Title ------------ ---- •--.•---- . .... ---... ..........- By ---- Of other than owner) FOR DEPARTMENT USE ONLY �.... .... DATE . . f `� APPLICATION ACCEPTED BY ------.... BUILDING PERMIT ISSUED .----- -----" -- ----- ADDITIONAL COMMENTS ---- i.1-------- - ---- --------- ............. ....... ...............• .... ... .� ............. ..................--......... ..._.... ....----•-------L.................._....I-------------- •--•---------- -•-....... . FinalInspection b ----_-- ..... ......------------------------------------_._...............'Date .......................... . EH 13 2h 1-68 1 v. 514 SAN JOAQUIN LOCAL HEALTH DISTR[CT 8/7h 3M