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FOR OFFICE USE :� A--- ..f _ APPLICATION FOR SANITATION PERMIT ----------------- -------------------- hh Permit No. ______- -. �,4 [Complete in Triplicate) - -- p�. ---- -----------------------------------------I. _--- This Permit Expires i Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and inst a wor erein described. This applicati"n is �m/ade in compliance with County Ordinance No. 549 and existing Rule and Regulations i JOB ADDRESS/LO TIO(` ------------ -------------------- CENSUS TRACT Owner's Name _ Z,,.__: ------------- ----------- Address 31 Phone - -------------- Contractor's -- Name '-----_- Cites . 5�- /-License # �� -- --r -------,..-- -- ---- Phone --- ----------------- Installation will serve. Residence [�Ap rtment House❑ Commercial:❑Trailer Court 0 Motel ❑Other _---- - ----------------------- ,` Number of living units:--;--1----_ Number of bedrooms --3----Garbage Grinder -- -..-_ Lot Size - `_--_-- -5 Water Supply. Public System and name -__---_ - -__- - - ----- --- - - ---- -- ----------------------------- Private [ � Character of soil to a dept, of 3 feet: SandEl Silt❑ Gay Peat❑ Sandy Loam ❑ Clay Loam_❑ Hardpan p Cl Adobe^❑--Fi1.l=fUlateYi l'_� :_ If yes, type --_ (Pfot plan, showing size of lot, location o.f•„systerri-i elation to�_wells, buifdings,�etc must be placed on reverse side.) NEW INSTALLATION: (No septic�ta 6r's'ee . �` �I � ge pit permitted if,public sewer is ava�lcibl�within 200 feet,} j + PACKAGE TREATMENT SEPT-1 TANK (` �/ /� y t . SE.P, t SIzeJ P__-/�--1P` --1_r---ir L'quid-Deptft-c Capacity _ �- .=�C3-----s- Type R. . -1.� 4. i 1 Yp Matenal- 'k��, -�--- No. Compartments astance to nearest: Wef) -__----_--- " --------- --_• - _ f - Foundation ------I-0 Prop. Line .- ----•_-_-- - LEACHING L1NE �I ` s [ Nil. of Lines .__ Total Len Length---------.-_ Length of each'.line---_--/p®--_-_.-_ D'� Box . s:•�� . �r� 9 :- --s�-E?�.-.-----•- --- Type Filter Matenai -_- - - _-,Depth Filter Material -_.- � t Depth o nearest--aA/ 11--- ?-`— -- # B e '------------ D ,s Foundation Property Line ---- __-- ---------- t7 SEEPAGE PIT � ° ' ' � �• - ---�_ pth ��: Di meter ---�--- Number --- ------- Rock Filled Yes No r0 Water Table Depth11 60---------------------Rock Size=3--i---------- ------------- - Distance to nearest: Well --------------- -0-_� Foundation Prop. Line _... REPAIR/ADDITION(Prev. Sanitation Permit# -_-- -_.._-_ - ---------------------------- Date ) ;r --------------- Septic Tank (Specify Req irements) -------- --------------- - Disposal Field (Specify (Requirements) ----------I- ---------- ----------------------------------------------- --------------------------------------- ----------------=------------------------------------------------------------------------------------------------------------------------------------------- ------------- --------------------istin----------------------------------------- (Draw exg and required addition on reverse side) I hereby certify that I haveiprepared this applicatipn 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 fo� which this permit is issued, I shall not employ any person in such manner as to become subject kman's Compensation laws of California." Signed -- ------- Owner- ---- BY - ------ -- ----- --- -- -- - -�, - - -- - ------ --- .,Title ---- -- - ----- �� (If of er than owner} '� ,y -------- i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- I BUILDING PERMIT ISSUED -_!p - ------------------------------------------------------------------------------------- -------------------------- ------. DATE " . - ADDITIONAL COMMENTS ---ll-------------- -------DATE ------------------ -- - ------------------ - ------------' ------------------------------------------------------ ---------------------------------- �� ----------------------------------------------------------------- -------------- F Final Inspection by: i --------=------- - -- - ------- ---------••----•---- - � ---- -------.Date --- ----- r r--- -- - --------- ----------• --- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. J.