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FORFFICE USE: �� Jig(� 15�' APPLICATION FOR ,SANITATION PERMIT ...._.... Permit N (Complete in Triplicate) This Permit Expires lYear From Date Issued Date Issued .5` ...:.. . Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein f described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..�� __��...-, �.. s......CENSUS TRACT .:.:...:.:....::.:..::.:.. Owner's Name ...... ... . ..... ................ . ......:............Phone i Address "----•--------------- 0..... _ City -- .. ... ........... .... Contractor's Name �1/� T- License -l --_-- PhoneC `./.. �'1:.... Installation will serve: Residence ]Apartment House-0 Commercial ❑Troller Court 0 ,4 Motel ❑Other ------------•- •--------------- ... ��Number of living units:. ------ Number of bedrooms ..._____Ga- ........rbage Grinder ............ Lot Size .............. Water Supply: Public System and name ............. ...............................Private* Character.of soil to a depth of 3 feet: Sand 0 Siit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ JHard anAdobe Fill Material ........_... lf. es, a --------------_-...._ -__ (Plot plan, showing size of lot, location of,system.,in relation to' wells, buildings,-etc. must be plated an reverse side.) NEW INSTALLATION:""""(N6 septic tarok or'seepage pit-permittedif public sewer is available within 200 feet,) PACKAGE:TREATMENT [ ] SEPTIC TANK i ] Size............. Liquid Depth ....... Capacity ............: Type --_-_ Material----------------' No. Compartments Distance ;to nearest: Well _______-�------------------------Foundation`:.....__.....`_.._... Prop. Line - y. I: -_ ..................... LEACHING No. of lines '------------------------- Length of each line.. '__ Tota(F Le'ngth. .......................... J D' Box : T. e_Filter Material : ...._. ------------ Type-Filter_ _ ....................Depth-Filter,�Niaterial°.._..---'--`-=..-.._"...-------•--•---...... =-•- � Distance to nearest: Well ._........ ... Foundation ...........1................='Property Line ........................ t ! SEEPAGE PIT [ ] Depth .................... Diameter ...._...' a._ Number ..__•+: ..__. ..:-.._...__ Rock Filled Yes E] No C3 �1 .w � • Water Table Depth ...................Rock Size Distance to nearest: Well .............. ......................... Foundation ..................... Prop.. Line ...................... REPAIR ADDITION Prev. Sanitation Permit# ............................................ Date .....:...........................] Septic Tank (Specify Requirements) € `- ,- _--- ..-----•------.._ .... . ----------- ...... ........ - �--{--........_ It •, Disposal Field {Specify Requirements) --. -•--- ;•:-- -: y ,-. __C�.t 33 X?i5 - :�-......................................... ....... . ....................................................... -------------------------------------- --•-----------•-----.--- existing and required addition on reverse side) i I hereby certify that f have pPepa"red this applicatidn_and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulaf hs of'the'San"Joaquin'L'ncal-Health District.-Home owner or licen- sed agents signature certifies the following: r "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 . . _------ _ - - .Title"...'" ----•-------•-•-•.............................. (if of er t a owner) F. D RTMENT USE ONLY APPLICATION ACCEPTED BY ....-_: f DATE .. - -- ------ --= --- -- ---..�...----------.._......._...........--•---•....................... .-jam. ......... BUILDING PERMIT ISSUED -•...... ... ` - ../ ...... . -_-@ .... TE ........................................... ADDITIONAL COMMENTS ..._.. .. 1.... .. 5. ...... .. ....1. y _..1.�........--•-• ..:.:.. .......................................... ......... �._........_........... .. .. ........ 1_-_�....---_. ..----......------ •....................... V. _ ........... .............. ... Final inspection E .-- .:: = -- — -. — ..............:.......:.....:....Date - . SAN JOAQU L LOCAL':�HEAUTH DISTRICT E. H.13 241-'68 Rev. 5M _ 7/723-114