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FOR OFFICE USE: , APPLICATION FOR SANITATION PERMIT ................ (Complete in Triplicate) Permit No. ........ "._........ F................ Date Issued Z9...�.7.... -- AA.................. This Permit Expires 1 Year From 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 with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATI N 1---- .. .......-...CENSUS TRACT .......................... Owner's Name .... .. ................. . -- --• --. .--- ----- •------- • ........... ...........Phone ............ Address 4..�.......... -�- ............. ----•- City ..., �'y (� ..................................------- Contractor's Nome ._....._-. ..._... It --.-- - ?�k.f^._icense # ��. - ._�_.. Phone ---....---•..... ...... Installation will serve. Residence Aportmen' House-E) Commercial ❑Trailer Court! Motel 0 Other [ Number of living units.,,....r..._, Number of bedrooms Com_._Garbage Grinder ------..... lot Size ............. Water Supply; Public System and name ...................... ... ¢ ......................Private Character of soil to a depth of 3 feet. Sand Silt❑ Clay ❑ Peat❑ /Sandy Loam ❑ Clay Loam ❑ } I Hardpan Adobe (] Fill Material _:: _....:.. If-yes, type ..................... (Plot plan, showingsize of lot, location of system in relation to Wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION.. (No septic tank or see age pit permitted i a public sewer is available within 200 feet,) X PACKAGE TREATMENT [ SEPTIC TANK f � / Size. _1�--------/�. ...._....._? Liquid C7 .. Depth ..... ................ , F` Capacity p Y lar,040 .-_.. Type . .... ............ Material..-�!!�,�,_ No. Compartments Distance to nearest: .Well ��•� - : �--••-Foundation ...�0, Prop. line _ W . ' f ....... .�.---. _- LEACHING LINE d --_,• No. of Lines ..._. .. len Length of each Total Length _....�..._.�..... n 'i]' Box _...,f T ype Filter Maferiai .�.`_�-�,--.•Depth Filter Material _..f.g_.... } Distance to nearest: Well—. _ _ .. ... ---- -•- -- �.,.__ Property Line _....._-_-�. SEEPAGE PIT [ Depth ... vim. S -- - Diameter �j --.�-�_ p '. _ .._---- Number .-----__cQ............. Rock Filled Yes �No Q Water Table Depth ----.___..... Q.. Rock Size ----------- Distance to nearest: Well ........ Q--Q.-- ------------- Foundation ` s 9 --..l..a. _... Prap. line .... a REPAIR/ADDITION(Prev. Sanitation Permit# ....:............4_- K.,_ _ _f._--....._ Rate ------------ Septic ------Septic Tank (Specify Requirements] { FR_ Disposal Field (Specify Requirements) .-..-___-_� ..---- ........................ ........................... ........... i ,.,�„__,(.. ra'w,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 Son 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 . ....._ - 4 Title : -Pt . ... (If other than owner) ........ == OR DEPARTMENT_ USE ONLY APPLICATION ACCEPTED BY .... DATE . (..3v..� BUILDING PERMIT ISSUED .......... --..... .. . _. _ . . .......... - ........ .............. ... ..............DATE ......._..... ADDITIONAL COMMENTS ................. .......... . ---------- --------------------------- - ----------------- ----------- ------ ....-- •---•-....---•--...._.....-----....._....._....---.....------...... .................... .. ......... ----- t' Final Inspection by: ....... ' . . Date ._..-. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 1-3 24 1.•68 Rev. 5M