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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p ....................................... .. 1i . Permit No: + /.f?�' iComplete in Triplicate) ._..--------- I...._............................... 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 with County Or finance No. 549 and existing,Rules and Regulations. ,� 4 JOB ADDRESS/LOCATION 1 �4;-.-, ... .. ... .....• ...... ;----•_--- ..............CENSUS TftACi �..._...._._._.._...._.... Owner's Name ......lV`. -._ .. ' , .... c -a1..... ...:......... Phone �...�.. - ... .... . T ...................................................................... Address •-•--• City � }� Contractor's Nome .._. lC t:.___. .....___... ..................:......License # -: .14.•_ Phone -- /Ls_. r�. Installation will serve: Residence ❑Apartment House❑ Commercial ATrailer Court Motel ❑Other ....................................-------- d Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size :.::�...._..._•_....... ............,,�__ f W � Water Supply: Public System and name ....................•.......................-------------------------------------------------------------- • Private A ' Character,of soil to a depth of 3 feet: Sand .Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ~Clay Loam ❑ �R 1 Hardpan ❑ . Adobe Fill Material ............ If yes,.type .................:.......... , (Plot plan, showing size of lot, location ofsystem in relation to wells, buildings,;etc. ,must.-be ploced,•on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is 9vailable within 200 feet,} PACKAGE TREATMENT SEPTIC TANK Sixe--- - -- _ -. - --- - Liquid Depth . i ..............• . t } Q ... T .... t Capacity ., Type _ X............ NVaterial_.Gf -71C......... Na. Compartments -g .............. r Distance to nearest: Well ..... .................Foundation ... ............ r0 p. Line .�_..-----_-_..:. LEACHING LINE No. of Lines .._/.................. Length of each line.-___._�:_. ..___._._... Total Lengt�- _ ............ . 'D' Box ............ Type Filter Material ------1__ ..Depth Filter Material ..... -• ........... Distance`to nearest; Welif .....i, Foundation _. Property ana ` eNSEEPAGE PIT Depth F -� _.. Diameter ...3.3.._.._ Number ._... Rock Fill i Water Table Depth .Rock Size Distance to nearest: Well /.. ....U .._.Foundation .....Prop. trine ................. REPAIR/ADDITION(Prev. Sanitation Permit# ....._...................................... Date ...................................11 Septic Tank (Specify Requirements) .---•............................. ...................... ............................................................................ ...... Disposal Field (Specify Requirements) .................I............ .................................—........................... .............I............... .........................................................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 mannas as to become subject to Workman's Compensation laws of California." r Signed Owner By .... . ... - ...._...... -•----•----.. Title .............................. ;........................... (If other than owner) Y OR ARTMENT USE ONLY APPLICATION ACCEPTED BY .... Z _ ar ............... ........ DATE BUILDING PERMIT ISSUED .....• �............. .... •.... ...........- ....DATE __.....__.......:::..:..:.._.. ADDITIONALCOMMENTS ... "" _ .......... ..............-...................................... -----.......__........._._. : ............................... .. ..................•. __._......------..-....._..--• ................ .. ---::: .. :::::::: Final Inspection by: _.......�.'... _ .. .............•--•---........--•-• i Date r .. . 7..�... i .SAN JOAQUIN -LOCAL HEALTH DISTRICT i E. H. 13 24 1-'68 Rev..5M .f - 7;/72 3 M,_-