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FOR OFFICE USE: I - APPLICATIOK.FOR SANITATION PERMIT Permit No: -------------------------- ------------- ---------- ---- r (Complete in Triplicate) ----- ------------------------------------ u �r .- Date Issued-_-�-7-�.j' This.Permit Expires 1 Year From Date issued ` Local Health District for a permit to construct and install the work herein Application is hereby made to the San Joaquin described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ;,?,) = ' " - - - -_ K )q ' " --.-CENSUS TRACT -------------- ----------- �� yd Owner's Name R -- ---------Phone - -- --��--- 1 "� 1 Ca `t ' -..------- _.__y } - i -� i -------------------- - City --------------------------- Address Contractor's Name --------------------- ---------------License # ------- -:-------------- Phone --------------- -------------- Installation will serve. Residence [.Apartment House❑ Commercial:❑Trailer Court ❑ Motel ❑Other -.------------------------- UA0-c r Number of living units:--_ _ Number of>'bedrooms _:_-a ----.--Garbage Grinder __,r u___ Lot Size -1 Water Supply: Public System and name --------------- ---------------- ----------------------------------------------------------------------------Private I1• Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Iff f' Hardpan IR Adobe F-1 Fill Material --.-- ------ if yes, type --__----------------------- I r (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 seep pit permitted if public sewer is available within 200 feet,) �- PACKAGE TREATMENT �SEPTICTANK' Size--- Liquid Depth --------------------------- W Capacity 1__r ___:.- -,-_ T e - ,�-; '�-- Material---------------------- No. Compartments _.-''.---------_-•-- p Y I=: = i YP istance to nearest: Well _----_1 ;~•_'---------------------Foundation ----_x _ ,-1--_-.--_ Prop. Line -__._. -------------- Length of each line--------`�' Total Length 1 :-{' LEACHING LINE [ No. of Lines - g - - E F 'D' Box - -- ,--- Type Filter Material --------------------Depth filter Material -------------------------------------------- Distance ---- ------------------------------•-.---•-Distance to nearest: Well -_r_--!_-------_--_- Foundation --.- '_-____---- Property Line ---- -<:"------------- SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number -------.-- ----------------- Rock Filled Yes ❑ No i❑ WaterTable Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ____-------------- ---__-Foundation -------------------- Prop. Line ---_-_-.__-_-_------__ REPAIR/ADDITION(Prev. Sanitation Permit# _.-_--_..----_---------------------- ------ Date ----.------------------.----------1 4 Septic Tank (Specify Requirements) --------------------- -------------------- ----------------------------------------------------------------------- 4 ir- Disposal Field (Specify Requirements) ----------------------------------- ------------------------ - ------------------- ------------------- ----------------- --- --------------------------------------------- - ------------------ -- ------------------------------------------------------------ (Draw existing and required addition on reverse side) I hereby certify that 1 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 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 subject to Workman's Compation laws of California." -- O caner5i ned BY - -------------=- ----------------------------- -- i -------------------------- ---- Title --- - ----- ---------------- ----------------------------==------------ - - ------ (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -------- ----- ---k2---ne--------------------------- ---------------------------- -------- DATE --- BUILDING PERMIT ISSUED ---------------------- -------------------- - ------------------------------- --------DATE ------------------------------------------- I ADDITIONAL COMMENTS --------------------------------- --------------------------------------- ---------------------------------------- -------------- --------------------------- - - ------------------------------------------- ----------- ------------------------------/ - ------------------------------------------------------------------- - - -------------- -------. Final inspection bY- a ------------- -- .-Date - ------ 1/Y- --- = j t SAN JOAQUIN LOCAL HEALTH DISTRICT i 1'A 9 1-'68 Rev. 5M.