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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT --------------------- -- ----- -------------------------- Permit No. (Completin Triplicate) .......... -------- ------------------------------------ This Permit Expires 1 Year From bate 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 ith County Ordinan No. 549 and existing Rules and Regulations: Cr - CENSUS TRACT JOB ADDRESS/LOCATI - --- - Owner's Name ---- � -- -y------ Phone Address ---------------------- C'r1 ---------------------------------------- City _t n ------- Contractor's Name -----J\,30 - ---- ---------------------------------- --------License #� f� L_ Phone ------------------_---------- Installation will serve. Residence n-Jerp-a-rtment House❑ Commercial ❑Trailer Court ;❑ Motel ❑Other ------------------------------------------ Number of living units:__________ Number of bedrooms __- ___Garbage Grinder ------------ Lot Size _,/ .., 4_i -______________ Water Supply: Public System and name ---------------------------------------------------------------.-- --------------------------------------------Private y -- Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material,_40___ If yes,type ____________________________ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) W NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available_within 200 feet,) PACKAGE TREATMENT f I SEPTIC TANK:jiR` Size__--1-�____-_� ____________________ Liquid Depth ._TN ------------ Capacity 1^10\00_____ Type `_ MaterialCZkl(_x' No. Compartments .-_ ............ 1 'r 0 , Distance to nearest: Well ----- -_-______-_--__•_-____Foundation _.__--_______-------__ Prop. Line __ __-______-_._ LEACHING LINE No. of Lines _ nn '�" 7.� --�----- -- Length o� each line_-f-� ______-- ----- Total Length /� ................. 'D' Box . Type Filter Material )ZL_9P-_4-Oepth Filter Material ------I.......................,_..__.____.. Distance to nearest: Well __ _�_____________ Foundation ____ Q__f__________ Property Line --- ------------------ Q SEEPAGE PIT IYI Depth I _ Diameter Number ______ ________ __J_____ Rock IFilled Yes W No 0 r1, P �y r Water Table Depth ------- 1 - ----------Rock Siie )_z?__ ` --- I Distance to nearest. Well --------_Qa________________________Foundation _-��__r_-_--... Prop. Line � _�__._..._.__ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) SepticTank (Specify Requirements) --------------------------------------------------------- ------------------------•-.------------------------------------------------------ Disposal Field (specify Requirements) ` ---------------------------------------------- --------------------------------------------- --------------- --------------------------------------------------------------------------------------------------- rr --------- ---- ------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------- (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 subject to Workman's Compensation laws of California." Signed ----------------------------------------------- Owner By --------------------------------------------------- V--- ---------------Title -- ZQfI (If other than owner) FOR DEPARt MENT USE ONLY APPLICATION ACCEPTED BY - ----- ------------------ - DATE �_f-. - -'------------------ BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- ADDITIONAL COMMENTS ------------------ ----- --------------------------------------------------------------------------------------- -------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - -------------------------------------------------------- --------------------- --- t _ Final Inspection by: ------------------------ � � Date a� SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M ��