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FOR'OFFICE USE: y APPLICATION FOR SANITATION PERMIT -----�--=Vii`----��--------------- z"--��`-"-`-'--- Permit No. (Complete in Triplicate),r ------------------ ----------- Date Issued Z y5-"?Y ---------=--------- - - 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: ? bP --------------CENSUS TRACT -----------------•--- ----- JOB ADDRESS/LOCATIO -- Owner's Name ----------- �� -- - Phone Address ------------------ -6-6'to---------- City --- - Contractor's Name ---------- --- cYa! License # -csr�: Il Phoner �.r� Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court !F] Motel ❑Other ------------------------------------------- _-_,- - ..,_. _ .-.... Number of living units:_._________ Number of bedrooms ___ ______Garbage Grinder __--------- Lot Size _________________ _____________ " Peat Sandy Loam """ " " "" """" Private Water Supply: Public System and_name .�---------- --------------------------•--------- n❑ AdO e Fill Material _____.___-" If es,t Clay Loam "❑ Character-of soil-to a depth of 3 feet:, Sand' Silt � Clay ❑ Y type ---------------------------- . Hardpa ❑ �. c� buildings, etc. must be placed on reverse side.) 6` f (Plot plan, showing size of lot, location of system in relation to wells, � [� NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 1 PACKAGE TREATMENT [ ] SEPTIC TANK ___._ Li Liquid Depth __ ________________,.- Si e K q P Ca acit � � Type _l -=---- Material" 7 'P� -- No. `Compartments "" --.•---------- pY -------- ---- -- r ' fi Foundation �V 7t---- Prop. Line --. --,t...---•- Distance to nearest: Well ____ --- ------- -- - LEACHING LINE �} No. of Lines --------- _____�---------- Length of eac line--------- Total Length �_Z -F-----_--•- ""-- - 9 rt � 4z, 'D' Box ----V---- Type Filter Material --------------------Depth Filter Material -----1_s _______•------------ ........ 41 Foundation I n""� --------- Property Line _.�--�--- • " " Distance to nearest: Well#___ �_-fi_---" - .� p y 3 '� Rock Filled Yes ❑ No I] Z SEEPAGE-PIT T Depth ----------- "€)iometer - Number} =:: i Water Table'.Depths--7-----------CUA - - - Rock Size -�J � G j T �----------Foundation ----/0--f---- Prop. Line --- -------•----- • .� ,Distance to nearest: Wel["'-___l."___________-- REPAIR%ADDITION(Prev. Sanitation Permit# ----------------- -- Date -------------------•----•---------) --- � Septic Tank (Specify Requirements) ___--------------------------------------------------------- ----------- "----- ------------------------ --• � � r ------------- - ------- Disposal Field (Specify Requirements) ------------- --------------------------------------------------- " "--""""" - fr_ . -------- -- x- ______________________________________________________ ___________________________________________________..____._______-_________..______-______ (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 Son Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "[ 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 -------- ----- - ---- - o Owner ------ Title -------- --�--------------------- ---------------------------- By ------- ----- (if othe t an owner) EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ---- ---------------------------------------------------------- DATE -- Z. =-7v BUILDING PERMIT ISSUED ------- DATE -------------------------------------------- ADDITIONALCOMMENTS ----- --- ---- - -------- ------ -- ------------------------I------------ ------------ Y - - - ------ ----- --------------------------------------- v Final Inspection b ------ - - ---- - -- -- ------ - -- Date SA JOAQUIiv LOCAL HEALTH DISTRICT E_ H. 9 1-'68 Rev. 5M