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J/ OFFICE USE. ?� d- FOR OF r APPLICATION FOR SANITATION PERMIT !/ A.11i 1Perm1t No. ' Sr {Complete in Triplicate) _ w . ... ......I This Penn]#Expires I YociFrom Date Issued Data Issued : :..............� Application is hereby made to the San-'Joaquin Local Health District for a permit to c`struct 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 .D / !:.. .�. � ,,,,,,, _ �...... . . .............CENSUS TRACT Owner's Name I`�'v .. .._.. .. _ 1.fir............................ Phone .��7`.��`��......._.. Address ,^.. r..". .� `_.. „> .??.._.._- 'City . .Ap-�*J e.............` ............. {� ... Contractor's Name ............. ...... ... .: " _ '...d .................License #A'N.3. ,�+...... Phone . �? - a...... installation will serve: Residence NApartment House Conimercial QTraller Court 0 Motel ❑Other ............... ....................... Number of living units:...-- ..... Number of bedrooms ...3......Garbage Grinder ............ Lot Size ........20..�........... f Water Supply: Public System and name Private to Character of soil to a depth of,3 feet: ' Sand❑ Silt❑-- Clay C1 Peat❑ .-Sandy Loam ❑ Clay Loam ❑ '^ Hardpan'(g ' Adobey' Fill Material ............ If yes,type ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse side.) NEW INSTALLATION: (No septic tank or seepage pit ;permitted if public sewer is"available within 200 feet,) i q p PACKAGE-TREATMENT [ SEPTIC M W ,%�' Size.--•._.• -f1C -_--• n �p .�.:.�........:.... Irl uid De th ... Copo I _.__• Type __K� - . Material....I..rf -~, No. Compartments ....7.... ..... = - -• Distance.to nearest: Well 4V...t ' Foundation . f C}.._ ..... Pro':Line . --- r LEACHING LINE N f e No. of Lines =` 'Len th of each lin ' -- ------•-- - -_•� 13,.. ---. .. ............... otahLength:..L Type Filter Material ..../r -..Depth Filter Material ........................... Distance-to nearest: Well ....: .. f Foundation ----/W4 ...... Property Line .. .f. ....... . M SEEPAGE PIT Depth .. _�-. } -Diameter _ 1?......._ Number ........17.................. Rock Filled ,Yes No 0 , Water Table Depth _.....--•--------•..............................Rock Size l�l�..x.. s , r Distance to nearest: Weft,...-:..r ._ `.....:.........Foundation --- Q':_. .... prop. Line --- ------------ REPAIR/ADDITION :--'----- REPAIR/ADDITION(Prov. Sanitation Permit# --------....--------------'-•----- ......... Dote ..........•.• ......... Septic Tank (Specify Requirements) _----------- ------------------------------- ' ; Wit" I Disposal Field (Specify Requir i'rien#s) - ----------------------- I(] t ----------------------- ,y ....................-------------------------------------------------------- (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 agents signature certifies the following: •- "1 certify that in the performance of the work for which this permit is issued,.l shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signed ------------------------------ --- Owner BY ------------ --------- Title '.._.----------...-•----.... ............ ------ (if a#her t an owner) . �9 DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - .. ..... •--- .. DATE . ....��; ,.��,-z-..._ BUILDING PERMIT ISSUED - %..: DATE '_... _._ ...:. .--- ADD#TIONAL COMMENTS -------- --- ---- ..... ..---....-----•. . - .. :... �.. ._.. -------�- -- (UI' _ ............................................... --------------------•-----....------ ---------, -••..................._.......................... ........................ --------•------------------- - -•• ----------•----•--•-----..----------------_..............------------------- Final Inspection by: ------ - ------- ..................................... ��... ... EH 13 2!t 1-68 SAN J AQUIN LOCAL HEALTH DISTRICT /74 3M