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FOR OFFICE USE: :*;. r4,' , ''^ APPLICATION FOR SANITATION PERINIT -,Permit No. - _ - -------------------- ---------------------- ----------.-____ ____.___---------------___------------- This Permit Expires ] Year From Date Ensued Date Issued I � 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: r JOB ADDRESS/LOCATION ------ , �(� ---CENSUS TRACT ----- ----------- ------ Owner's Name one ----------------------------------------- --- -------Ph --1� Address Cit .� i -------------•- Y 1 ----------------- --------------- ' Contractor's Name --- -------------License # __i._ --- Phone Installation will serve: Residence[$Apartment House❑ Commercial :❑Trader Court ;❑ Motel ❑Other r ( Number of living units:---,/-- Number of bedrooms__3______Garbage Grinder - ----- Lot Size y ---------------- A Supply: Public System and name --------- _ _______Private E-1 ' s t Character of soil to a depth of 3 feet: Sand'[] ilt❑ Clay ❑ Peat❑ Sandy Loam •0 Clay Loam; i ; # t ¢ Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes, type I -------------------------- ---------- (Plot 'plan, __________-_______.____(Plot 'plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1 NEW-INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �3 PACKAGE TREATMENT [ ] SEPTIC TANK![ l Size._ .�'/'�.Z' --------------------- Liquid Depth __y__ '- .----__. � I'I Capacity 4200-------- Type �- - d l*� _& No. Compartments E R, �_ Material - _ ---�-------------- Distance to nearest: Well ------------------------------------Foundation ---------------,------- Prop. Line --_----------�_.__..._ LEACHING LINE ""[ ]�'"`° No:of'Lines _______________________ Ce`rigth"of"eadi line_` _ w�__--_" Total Length ----------- - 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- -------- ' Distance to nearest: Well ________________________ Foundation= ` -� SEEPAGE PIT [ ] Depth -------------------- Diameter `'` Property Line ---- -------_i_-- --------------- Number . --- Rock Filled Yes No Water Table Depth ------------------------------------------------Rock Size ----------- -------------------- Distance ----- - Distance to nearest: Well ----------------------------------------Foundatibn_..-......------------ Prop. Line ------------------•-- REPAIR/ADDITION e( (Prev. Sanitation Permit# ____________________________ _--a e _ ---Tb —i )- teia t_ _, � _: a,Se tic Tank (Specify Requirements) -------- ----------------- = _:._ " -_--- i Dis'posal Field (Specify Requirements) --------------- -------s- ---- - -t w :------------------------ i------------------------, -------- ---------- ------------------------- -------------------------------------t--------------------------------------------- - --------------=) -- ° (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 Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- sed a ents 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 b as toecome subject to Workman's Compensation laws of California." i -- ----- -------------- -- --------------------------- Signed ---------- O F s f ---------- TiItie - ---------- (If other than owner) i ? t # i' FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY `--------- = w ' DATE y _l7[7 BUILDING PERMIT ISSUED _ . 7 _ f ' ] DATE ADDITIONAL COMMENTS --ct #' - -�1} - --lr f_ _-— \= 1 Q �4r _ - = 1 e ---------------]------------------------------------------------------------- , - ---- -- -----------------•-----------------------------i--- -� -- -- --------------- - ---------- $E , I Final nspection by: _ ._� _+�---- ---- ` .- , ' Date -_r. _-.___- a' - ------------------------------------ -- l -- --=--------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68.Rev.:.SM 4