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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - Permit No. ------------- ;Complete in Triplicate) -- - ------_----_-_ --- ---- ------------ This Permit Expires I Year From Date Issued Date Issued ---C`�--73_ ----- ---- Application is hereby made to the Son 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 --------------------------- -- ---CENSUS TRACT ---`�--11-T.---------- - 1-�--��-��-----�-f•�' ---�---��%��'-= Owner's Name ----- '------------------------------------------------=---------------------Phone --------------------------•--------- , --_. Y ------------------------------------------ Address : Contractor's Name ----------------------------------------.License P h a n e Installation will serve: Residence NeApartment House ❑ Commercial ❑Trailer Court ;❑ {. Mote! ❑ Other ---------- ----------------------- I Number of living units:._ ____ Number of bedrooms &l L Garbage Grinder;r7--- Lot Size � _ t Water Supply: Public System and name -------------------------------------- ------------------------------------------------------------------------PrivateX Character of soil to a depth of 3 feet: Sand'F Silt❑ Clay 0: ,Peat❑ Sandy Loam [] Clay Loam 3 Hardpan ❑ Adobe '❑ Fill Material ----- ------ If yes, pe -------------_______________ (Pl'ot 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 ---------- -------------------,-----a acit _ - Type -------------------- Material--------------------- No. Compartments ---------------------- ' -----------= Dist nce t6, nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------- --- LEACHING LINE [ ] No, of Lines' _.__________________ Length of each line----------._._______.______ Total Length ,_____.__ I � ; D Box _____._____ Iype Filter Material ___________________ pth Filter Material -___________________________________..__... Distance to nearest: Well _ __- _______________ Foundation 4 ..____------------------ Property Line ----____________-__--_- SEEPAGE PIT""[-1`Depth ____________________ Diameter ________________ Ndmber --------------------t,______ Rock Filled Yes ❑ No i❑' I Water Table Depth Rbck-Size,a-•---__.__ _r ._T_. t Distance to nearest: Well _------ -----------------..._ ______Foundation -------------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------`----------------------- Date --------.-------------------------1 J Septic Tank (Specify,Requirements) - ---------- f� __ _-��----� --'--�� _-----�� -------------------- ------------------------------ I Disposal Field {Specify Requirements) wy - {� �: �� e-�-- ► T�---------------- ;, --------------------------------------- ------------- --------- _ — - {Draw existing and required addition on reverse side} 1 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 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 Compensation laws of California." Signed ----- ------------------------------------------ Owner BY ------------ ---=------- = Title "--------------------------------- ,r other than owner) t FOR DEPARTMENT USE ONLY �` APPLICATION ACCEPTED-BY - ------- - f��G=---------------------------------------------------------------- DATE �_ -- ----------------- BUILDING PERMIT ISSUED " -------------------------------------- ----------------------------- DATE _.- ADDITIONALCOMMENTS ----------------------- ------------------------------------------------------------------------------ ---------------------------------------------- ----------------------------------------------------- ---------- ---------------------------------------------------°-1------------------------------------------------------- ---------------------------------- ------ Final Ins p ection b ---------------------------------Date k7 __ -. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M �' `` ,4 -'e