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FOR OFFICE USE: �r_ APPLICATION FOR SANITATION PERMIT f Permit No'-- 7�'3------- (Complete in Triplicate) ----- ----- 3 � -3~7. ----------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _1' 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/LOCAT N .--- -,-- ---------------------------------CENSUS TRACT ----------------..__.._.. Owner's Name _.___ ----- ------- --------- - ----- ---------Phone --- i Address ------------- = Cit _ J _ Contractor's Name _-__ Cif � "tf"cense # -- --- Phone -� =-/d I � Installation will serve: Residence ['Apartment House ❑ Commercial ❑Trailer Court- ❑ Motel ❑Other -------------------------------------------- ' Number of living units:---._!_-___ Number of bedrooms _____c9,-Garbage Grinder ___________ Lot Size -----Z -----_-___._____. Water Supply: Public System and name ----------------------------------------------------------------------- ----------------------------------------Private [a - I Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe Fill Material ____________ If yes, type _______________________ W (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) V) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth -------------------------- � Capacity -------------------- Type - -- ----- ------- Material No. Compartments ------------------•--- f t 4 Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line _____________:_-______ le LEACHING LINE No. of Lines �' �(] --.----- ---- Length of each line-'------- 4�_ -- ___-- Total Length -----� __ _______-- 47 'D' Box ----- Type Filter Material ------�--__--Depth Filte.P Mater-ial -------f --------------------- We ___________________ i. Distance to nearest: Well _____ Foundation __-_.__,l` ________° Property Line ____ __._.___ SEEPAGE PIT lVl Depth ---- - Diameter Wit- Number -----_-------- ____.-----'Rock Filled Yes .5� No i❑ Water Table Dept -----------h_`- ----------------L------Rock Size ------- f Distance to nearest- Well -----"IX:11___f_______------------Foundati.on ------ Prop. Line REPAIR/ADDITION(Prev. Sanitation Permit# ________ _ Date _ _____________ ________ Septic Tank (Specify Requirements) - - -; - -------- / �'_-{ -- - --------------------- Disposal Field (Specify Requirements) ______ __ .___.�Af -- i --.^----- -gra---- _ --. h ' S ---------------- ---- - - -------------------------- ---------------------tl---------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) i 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: E ? i "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 ---------------------- ----- ----- - Owners: Q 1'+. - } 3 BYrc_- ----- - --------- --------------------------------=':- Title ------ (If other than owner) ' 1 EPARTMENT USE ONLY APPLICATION ACCEPTED BY ______ ------ - ---------------------------------------------------------- DATE ____ _~_ .__ j BUILDING PERMIT ISSUED .. -. -- ---------------------------.:__.___—_ ,-----------t--- DATE ADDITIONAL COMMENT ------ --- ----------------------------------- - -�1 ' --�----------- rig d----- � _____________________ ________ _____ __ _______________.___________-____________________________ Final Inspection by: ------ - --- -------- ----------------------------------------------------------------------.Date -' "a4=Jj USAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M