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FOR OFFICE USE: ............... APPLICATION FOR SANITATION PERMIT ------------... ......... (Complete in Triplicate) Permit No. ..72 .�U.... ............. This Permit Expires it Year From Date Issued Data 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: JOB ADDRESS/LOCATIO f� .._..I 5�.�_a.._..._.�......��J. �� .....,A... ..�.-�.....cl:Nsus TRACT ......... ............._.. 4 . r Owner's Name . ..-,moi. ._ . :.... Phone ..... ... ........................ Address . .. .._ ... - ..Z,. ...---. . ;t .. .... .... �-- _ Clty ................. ...... ....... .._._.��...`f-�./..`�....-•----._. . Contractor's Name Cc� ..• "1.-`74. e._... ..'�.: ...............License # ..�.��?3 �. Phone .............................. Installation will serve: Residence�ortment Housefl Commercial []Trailer Court 0 Motel ❑Other ............................................ Number of living units:__.1... Number of bedrooms .s3.....Garbage �Grinder ............ Lot Size _4' �-�-��a—............. Water Supply: Public System and name ............................................_...... IC/ – ...............................Private ❑ . Character of soil to a depth of 3 feet: Sand❑ Silt❑ Cloy ❑ Peat❑ Sandy Loam {3 Cloy Loam [a— Hardpan Q Adobe ❑ Fill Material ..._ ....... If yes,type ............... ............ (Plot plan, 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 seepage pit permitted if public sewer Is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size---•........................................... Liquid Depth ................ Capacity --- ---------------- Type ----•............... Material...................... No. Compartments ......................6 Distance.to nearest: Well ....................................Foundation ...................... Prop. Line ..................... LEACHING LINE [ ] No. of Lines .........---------..: -- Length of each line............................. Total Length D' Box 'type Filter Material ......Depth Filter Material Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ ( Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No C� Water Table Depth ------ ------------------------------------------Rock Size ................................ Distance to nearest: Well __....................................foundation .................... Prop. Line ......................0p REPAIR/ADDITION(Prev. Sanitation Permit# ................_._......................... Date ..................................) GO Septic Tank (Specify Requirements) _:.. Disposal Field (Specify Requirements) -- "._l_ •k._l ......... p-.. ...........�.... ..{ Q ---- --- r•• s. •--C - ` 1.La -----------------------------------------------•.....-.................................................------..................................... (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 Jeaquln 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, 1 shall not employ any person In such manner as to become subject to Workman's Compensation laws of California." Signed Owner BY - -------------------_---. J'itle _ . ._. (If other than owner) OR DEPARTMENY USE ONLY APPLICATION ACCEPTED BY ------ - ------ - -----------•- •------------_-------------................_._.._.._.. DATE .._.. .. .�`. _...... BUILDING PERMIT ISSUED _.._..-----•-- - •-- ------------•-_----..._..-------------- ...._._..-.......DATE .... . .................. ADDITIONALCOMMENTS -._... -•-------------------------- -------- ............................................. ....................-.............. ............. --------- ---------- ---------- --------------- ----------------------------•-------- ..................................................... -•.................................... --•- _-------....-•--------- ----- �. Final Inspection by ._Date .... r] IH 13 24 1-68 Rev. 5m JOACQUIN LOCAL HEALTH DISTRICT 6/7li 3M