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FOR OFFICE USE: .... APPLICATION FOR SANITATION PERMIT Permit No. iComplete in Triplicate) ............................................ i .... ....... .... This Permit Expires II Year From Date Issued Do4I;ssued, .S.-C71L... Application is hereby made to the Son Joaquin local Health District for a permit to construct and Install they work herein,' described. This application-is.made in compliance vyith County Ordinance No- 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI e�.-�� CENSUS TRACT .......................... Owner's Name -" ' W � Phone ..... ... .................. �+ ... Address ... ,..,_..._.. {. Contractor's Name ----- ��• Phone - (ci d� �Z' License tt` .-...... rInstallation will serve: Residence Apartment:House 0 Commercial ❑Trailer Court 0 Motel []Other ..---•------- Number of living units:...... _.. Number of bedrooms ......Garbage Grinder _........... Lot Size Water SupplPublic System and name ....Private (�' - Character of soil to a depth of 3 feet: Sand o Sift❑ Clay ❑ Peat o Sandy Loam jo Clay i.oam ❑ I Hardpan❑ Adobe 0 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, aide.) NEW INSTALLATION (No septic tank or seepage pit .permitted If public sewer is avoilable'w#thin 200 feet,) PACKAGE .. VC TREATMENT [ ] SEPTIC TANK f } . Size.-- , ./.- ........... Liquid. Depth .......................... Capacity� d a Type { Material----lam ........ No. Compartments ..4e.............. Distance too nearest: Well .J__.._, t............Foundation .110.1Q............-. Prop. Line ..,;Ziyl••:......QO' LEACHING LINE [ No. of Lines ..............•.-•._.. -_111111 Length of each line............... __...._...... Total Length ---.--.................:.... (VJ� 'D' Sax •-- -.------ Type Filter Material ....................Depth Filter Materia! Distance to nearest: Well -------------------- Foundation ------------------------ Property Line .........:............. ,.. SEEPAGE PIT ( ] Depth --.--1-------------- Diameter ------- ........ Number ...._.-- ......_•------- Rock Filled Yes ❑ No OE i Water Table Depth --------------.------I.........._----------------Rock Size -_:-_............. Distance to'nearest: Well --- ---,•---------------------------Foundation -•-__-----........ Prop.,, Line .............. � b REPAIR/ADDITION(Prev. Sanitation.Permit+# _ ._--..•- ---------------------•-- --•_-.. Date ...... _ ) Septic Tank {Specify Requirements) ! ------ • .................................................... Disposal Field (Specify, Requirements) .... -------------- ------------------•--•--------:-----.....-_-----•---....-------......-•-_•-••------•------......-----•-- ----- -1-__---•---------------------------- -----•--------------------------- • . ----------•-•------:_--------- ----------------------- ---------------------------------------------------......... F (Draw existing and required addition on reverse side) U hereby certify that I have prepared this application and that the work will be done In accordance with San Joaquin County Ordinances, State Laws, arid Rules and Regulations of the San Joaquin Local Health.Dlstrict. 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." Signe •-------------------------------- Owner B ------- Tit#e .. r llf other th owner) { FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _._ - DATE . �. .. BUILDING PERMIT ISSUED`------------- -- ------ -- ----- --- ----••-•----- (/---••-' ------------- ---.-..-..DATE ....... _ -•------.----- ADDITIONAL COMMENTS ---- . - ._... - •--------_..._..... .._ -•-----------• ---•-•.................................... ----..........._.. ..................... Final Inspection by: .. --------------------- ----•.Date - .'. .-..--------•- ' •..... EH �3 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M i