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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Pe -------------------------------- rmit No. ___-_ -- 53 ------ /1 ---------------------------- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby madeao 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. 3.49 and existing Rules and Regulations: JOB ADDRESS/LOCATI -__- - -- - ------ ----------- ------ ----------- ---------- --CENSUS TRACT -------------- Owner's Name ii -ate lit -------- �, Phone Address ---- --1,ol-- - -- =- _ City - -- - -��-------------------------------------------------------- i 4 Contractor's Name ---__- -- License # Phone Installation will serve:: Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other Number of living'uni.t's: --- -I.-_- Number of bedrooms------Garbage Grinder ------------ Lot Size --_- Water Supply: Public System and name _________________ ----------------Private Character of soil to a depth of 3 feet: Sand'[] Silt 0 Clay .❑ Peat❑ Sandy Loam -Z Clay Loam;❑ i Hardpan ❑ Adobe ❑ Fill Material ------------ Ifes, Y type ---------------- ---------- (Plot pian, 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 seep ge pit permittedif ublic sewer is available within 200 feet,) 4 / \ PACKAGE TRl_ATMENT ['j "`SEPTIC TANK - Size f f�__�{� Liquid Depth ___ ------ q p 4/------------------- Capacity ___ TYPe Compartments --- l-- ---------=---- Distance to neare : 'Weil:..---- ka__/tt-_'_____----I-Foundation ---�d_-f___ __ / 1 - ----. Prop. Line .----�..--------•- LEACHING LINE [ No, of Lines ------3------------- Length of each line-------FQ________------ Total Length P__--_-.-______- q 'D' Box _ Type Filter Materia!" __-_S_ _ -Depth Filter Material ------/_. ---------.._... r Distance to.nearest: Well ------------------------ Foundation L0-_--______ . ,..., ' t -------- - Property Line ---`s--------•--------- SEEPAGE PIT [ ] Depth r----------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No 0 Water Table Depth- ----------------------=-----------------------t Rock Size ------------------------- .,z- ! Distance to nearest: Well ---------------- --------Foundation -------------------- Prop. Line ...------------_--- - REPAIR%ADDITION(Prev- Sanitation Permit# -------------------------------------------- Date ____---_-_-_____________ ) i Septic Tank (Specify Requirements) --------------------------------------------- ----- - Disposal Field.,,(Specify Requirements)-- __________________ .� (Draw existing and required addition on reverse side) I hereby certify that I have;piepared this application and that the work will be done-in accordance with San Joaquin I 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 sublet Workman's Compensation laws of California." Signed ------------------- _ -------------- Owner - --------- ----- --- ------ -- - ------ ---- BY --------------------------- n.3- 9'"` - = ------------- title (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------------------------------------- ----------------- ------------- -- - - • DATE .'?--f _ ------- BUILDING PERMIT ISSUED ---------------------------- -- - -- -- - -- - - ----- - ----------------------- ------------ --------DATEADDITION - ----------------- ----------- - - - ------------------------ AL COMMENTS --- ---------------- - -------------- ---------------------------------------------------------------------------------------- ----------- - � = ------------------------------------------------------------------------------------- -----------------------------------•----- 4 --_- �. _____________________________________._.'__ Final Ins ection b = ----- p 1 Y: ------- -- -- --------.Date 7---__ __ ---- -----------•------- SAN JOAQUIN LOCAL HEALTH DISTRICT ;I E. H. 9 1-'68 Rev. 5M.