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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No- . �--------- ---------__--------- - ---------__--------- --------- ------- (Complete in Triplicate) . -------------------------------------- 70 Date Issued --- ----•• ' • 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: ------------ -CENSUS TRACT ----------- ------- JOB ADDRESS/LOCATION .��1'- ----�� U ,(/ ► . Owner's Name -�- � -- -�------------------------------------ -:-----.Phone .- �--�- --1� •-----•--- . city STS. fQ�/ Address O� ----- - f�l/F- Y el Contractor's Namee-Z—--------------License # -/7->q-S"3--- Phone -1 -L--- Installation will serve: Residence M Apartment House❑ Commercial :❑Trailer Court ;❑ Motel ❑Other -------------------------------------------- Number of Sliving nits:--- Number of bedrooms -�------GarlFage Grinder A&---- Lot Size Sa!_-a'� Q-r---------------- Water Supply: Public System and name ---------------- --- -- --- -- Private .- i Character of soil to a depth of 3 feet: Sand'❑.` Silt❑ Clay ❑ Peat❑ Sandy Loom Clay Loam .0 Hardpan ❑ Adobe ❑ Fill Material -___.._W.. 'If yes,type ------ .----------- {Plot plan, showing size of lot, location of system in relatiorito 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,) PACKAGE TREATMENT [ ] SEPTICTANK'M Size-'- _�2`_s`�--------------------- Liquid Depth .-----------------. rCgpacity /a2al- Type��-CX5T' Compartments 4_1:�---- ------------- \ ---Foundation ../O_- ------ Prop. Line --.<-- ----------- t Distance to� nearest: Well ---.___---_-__--�___;�'-Pl- a � � --------_:-- Length of each line.---- --- Total Length L 4-.•----_------- F` LEACHING LINE [ No. of lines -- 9 'D• Box --- Type Filter Material _ (9G-K------Depth Filter Material -.1 ----------------------- Distance to nearest: Well ----- ------- Foundation .--1..- `_-..--- ---Property Line. -'- -- -" SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number _.-------------------------- Rock Filled .Yes '❑ No 0 WaterTable Depth ------------------------------------------------Rock Size ------------------------------- Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---_------------------ k REPAIR/ADDITION[Prev. Sanitation Permit# ------------------------------------- ------ Date ----------------------------------) Septic Tank (Specify Requirements) --__--------------_ -------- Disposal Field (Specify Requirements) -----.-____:------------------------------ ----------------------------- -------------------- --------------.:- ------------------------------------------------------------------------------------------------------------------------- --_---- - ---_- (Draw existing and required addition on reverse side) - —=_ =-n----- 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 Work on's Compensation laws of California." Signed ----------------- Owner ` By _____ ---- Title --------------- ------------------------------------------------------- ` (If other than owner) FOR DEPARTMENT USE LY i -- ------ DATE�t--. DATE ------�.c�.�-�L-------------- ----- r APPLICATION ACCEPTED BY -------------=-------------------------- ------- ----------- BUILDING PERMIT ISSUED ----------------------------------------------------- DATE ADDITIONAL COMMENTS ---------------------- ----------------- ----- ------------- ------ ---------------------------------------------------------------------------------------------------- ------- - - -- -------------------------------------------------- - Final Inspection b � _---.Date _-- -�- ----"- -- - ---- �------- p y SAN JOAQUIN LOCAL HEAL DISTRICT r E. H. 9 1-'68 Rev. 5M.