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FOR OFFICE USE: , � — APPLICATION FOR SANITATION PERMIT k ----_ ,--- - ^,� (Complete in Triplicate) Permit No. -._ -- •------. 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 made in compliance jth C my Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION .- 3 j ------------------- ----CENSUS TRACT Owner's Name ' i ---..-------Phone Address ------ Contractor's Nameq-F ------- - - -�. -- ------------ - ---• . City -- -- - ---------- ------------------------------------•------•-- ------------ - -License # -��.l�c��Phone ------------ Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ I I Motel ❑ Other --------------------- ------------- Number of living units:----- Number of bedrooms I __,3------Garbage Grinder Lot Size_.___ _l(S �C 3 w ---------------------•-•--- Water Supply: Public System and name _____-_E__!---_____ Private [ � Character of soil to a depth of 3 feet: Sand'0 # Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑r Adobe.E Fill Material ------------ If yes, type ___--_._.__________________ (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] PACKAGE TREATMENT [,g— SEPTIC TANK'[ I ). Size-------- ------ "______ �5 x-G Liquid Depth 4 / ------------------ Capacity Type -- Material_jnr_-wNo. Compartments Z_________________ Q Distance to; nearest: Well ___� _ Foundation __��--------_----- Prop. Line -��--:_______-- LEACHING LINE [tfi No. of"Lines ""___3______________ Length of each line---kO- -_._____________ Total Length __ _ p_�_____ ----- I' f 'D' Box._ _ Type Filter Material :7�'E-------Depth Filter Material - ��V! 1 Distance to nearest: Well SD `--------------- Foundation _/6_ -------- Property Line. _-S-r__-________. -- SEEPAGE PIT [ ] Depth _._.__ _--__ Diameter �._. f ( ------------- -- Number -.--------------.---------- Rock Filled Yes '❑ No .10 Water Table Depth -----------------------------------------------Rock Size L Distance to nearest:-Well-" ----- -- -------- -Foundation ____________________ Prop. Line _._____.__________ REPAIR/ADDITION(Prev. Sanitation Permit# __________________ Date __-_-______________,_--________ -- } Septic Tank.(Specify,Requirements) _____________________ i Disposal Field (Specify Requirements) -------------------------------- - - - - - i � vy ______ __-____ _______ _ _____ ____ _________ _ __-.___.___.___- -.___-__.____ ______ ___.__________ ___.-________ _____ ___.__-___-_____ _______ -- -- _ _ ____�________.-_____.-__-._____ __ -_____________. .__ i (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 �yb'ect to Workm n's Compensation laws of California." Signed - Owner --------------------------------------------- �._ ...... By --------------------------------------------- ------- ------ ------------------------------------- Title -------- -------------------- ----------- (If other than owner] � -�- -�4 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- D ADDITIONAL COMMENTS ------------ ATE ------------ ---------- BUILDING PERMIT ISSUED -------------- ----------- -- ------------------DATE --- - - - - -------------- ---1-- ------------ --------- - - -- -------- - ,-- --------------------------------------- ------ ----------------------------------------------- ------------------------------ s4 Final Inspection b ---------------.Date --- - --- - SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �''�