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FOR OFFICE USE: APPLICATION FOR.4ANITFATION PERMIT ------------------------------------------------------- Permit No. [Complete in Triplicate) This Permit Expires 1 Year From Date issued Date issued s- - --- ------------------------------------------ -------------- 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/LOCATION .__-- - -1711------ ----� -- -- - ----- ---------------------.-----CENSUS TRACT -------------------------- ----------- qq GG Owner's Name - ----- - ---=- - Phone . 3�- Address - --- --- City - # yq/ License - . Contractor's Name ------ -- -------- -•----- --- -- Phon� 7 _~_!_oQ 7-- Installation will serve: Residence ❑ Apartment House[] Commercial :❑Trailer Court i❑ Motel ❑ Other -------------------------------------------- Number ------------------------------------------Number of living units:---I------ Number of bedrooms -1-----Garbage Grinder ------------- Lot Size ---------- -------------- Water Supply: Public System and name ---------------------- ----------------------------------------------------------- ---Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ,❑ Hardpan ❑ 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 [ ] Size------------------------------------------------ Liquid Depth -------------------------- Capacity ------ ------------- Type -------------------- Material---------------------- .No. Compartments -----------------=---- Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- LEACHING -----.------ ------LEACHING LINE [ 3 No. of Lines - ---------------------- Length of each line---------------I :----------- Total Length ---------------•----------- a 'D' Box ._ -__�" Type Filfer Material ________ -----------Depth Filter Material -----------------------------------.----_---- "* -------------------=---- Distance to nearest: Well ______________________ F`oundation---____-_-_'_-_____��-�_�^Property Line SEEPAGE PIT [ ] Depth . _ __ ------------- Diameter ______-___-____ Number `- y__--------------- ', Rock Filled Yes No I❑ 4 Water Table Depth --------- ------------- R0ck_Siie = -"--------- ---------- --- -- ---- -- � I � Distance nearest:Wel,l;' t t-Y �----------------- ------ Foundation ------ --------=„_ Prop. Lie -------------:------•- it V0 {Prev. Sanitation Permit# ------------------------------------'.------ Date --------- ----------------------- REPAIR/ADDITION 1 � Septic Tank (Specify Requirements) ---- -------------------�--- ---- ]� ---:-•----------vu, ; I Disposal Field {Specify Requirements) ---------------( ------ ' ►��% -- ------ --i'i r_.__ ____'___'_---------- t I :_� - -�-�-, -- ------------ � , ----------------------T------------------------------------ --------- d-K--------------- -- ------------ -------- t d (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~'ac ordance with Sari 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: t "I certify that in the performance of the work for which this permit is issu ted, I sholi<not employ any person in such manner as to become subject to Workman's Compensation laws of Cato nr iaI Signed --- --- ------- ------------------ ----- ------------- Owner-- "g ------- t----- ------------ Title --------------- 7 l'------------- --------------------------- (If other t owner) FOR DEPARTMENT USE ONLY ------------------------ DATE _ j/�'��J . --------------- PPLICATION ACCEPTED ACCEPTED BY # -- - - --- -- ------------------------------------ BUILDING PERMIT ISSUED._----- ------------------------ ------------ ---------:-.,.:=---:---- DATE ADDITIONALCOMMENTS -------------------------------------- ----------------------------------------------------------------------------------------------------------- -:-------- r-1 : w t+., ---------------------------------------------------------------------------------------- - ------ 1 It v -----k�)----------------------- -------------------- ---- ------- --------, ---------------- ------------------------------------ -----'T-�7 -------------------------- (J y� Final Inspection by- ---- / --------------- --------------------------------Date SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.