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FOR OFFICE USE: ' e • APPLICATION FOR SANITATION -'PERMIT ................ ............................ / Permit No. ••-'.-•--•• (Complete Triplicate) �4� "' "-"••' ................... ........................................................ This Permit Expires I Year From bate Issued 7s1/o 3 S— bate 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 rm�adde in compliance with County Ordinance Na, 549 and existing Rules and Regulations: JOB ADDRESS/LOC ON .....l..u. _.... f...... ........CENSUS TRACT ......................... Owner's Name .. ........... . -- --•-...............Phone .. ..... Address --........ City ....................... ..........--.._._....... ...... s j g Contractor's Name ...... . . ._. .... License # . -7 �.7�. Phone Installation will serve: Residence [v'Apar ment House-0 Commercial ❑Trailer Court 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❑ Clay ❑ P ❑ Sandy Loam ❑ Cloy Loam ❑ Hardpan [3 Adobe �` Fil Mier ._.__.------ If yes,type ............................ (Plot pian, showing size of lot, location of systee i re ation 4ell , buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage`pl erm1ttif public sewer is available within 200 feet,} PACKAGE TREATMENT [ .] SEPTIC TANK ] Size................................................ Liquid Depth .......................... Ca ci y .... ------ Type .................... Material...................... No. Compartments ...................... istonc nearest: Well ______--- ..................Foundation ... Prop. Line 00 LEACHING LINE [ ] No f Lines ------------------------ Length of each line----------------------------- Total Length ............................ V 'D' Box ............ Type Filter Material ....................Depth Filter Material ................I.........--------I......... Distance to nearest: Well ........................ Foundation __ Property Line .. Rock Filled Yes No SEEPAGE PIT [ ] Depth —,---------------- Diameter ................ Number ..-----•--------------•-- ❑ [� Water Table Depth ..... ...........Rock Size ................................ f1 Distance to nearest: Well ........................................Foundation .................... Prop. line ...................... Septic Tank (Specify Requirements) __......... - } g REPAIR/ADDITION(Prev. Sanitation Permit# ... ................................... Date ---. P .2- Disposal Field (Specify Requirements) _..- (fie 1.-- - s�..c ,t�...............• -------------------------- ------------------------ -----------------------------------------------------------------------------............---•--.................................................. . (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 thisrpermit 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 .._. - F .... Title .. � _.�. .... .......... .. r .... ._ ._ ._._.._......_._..._........_._.._____.... (if other than owner) FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED B ,, .. (/ .-.-............................••••..._._.._...._..••--.. DATE ........... BUILDING PERMIT ISSUED ........................... ----------....-----...........DATE ........................................... ADDITIONALCOMMENTS ........................................................................ -------------- ............ .............................•-- ..................... = ....................................................................................... . .. .... .--••----- ... ............•................... T. Final Inspection by: t - .._._... Date . _ ............... SAN JOAQUIN LOCAL HEALTH DISTRICT � a W. --E. H. 13 24 1-'68 Rev-5M. `_ - - 7/723 11I