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FOR OFFICE USE: APPLICATION F.OR., ANITATION PERMIT t. .. IV? ------ --------- --�---------- ----------::-�= . .. ... _ w ,.Permit No._-- -,--X---- -- - (Complete'in Triplicate} ------------- --------------------------------- Date Issued -`_Af& This Permit Expires 1 Year From Date Issued 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- ..... egulations: ADDRESS/LOCATION-_ -- - ''A --------- JOB ' CENSUS TRACT --------------- - , Owner's Name _' .Phone.f. - - -Z> i -t-1 ' - ---------------------- Address - �' City ----- -------- ------ ------ ----- --------_------ ----- ---- --- - Contractor's Name ----- ; = --_ 1 __.License # ---- -------- Phone Installation will serve. Residence ❑Apartment House,Q Commercial ❑Trailer Court-7;❑ Motel ❑Other - ' _li_ _ 0 --- Lot Size ---•-- Number of living units:....______. Number of bedroorr}s :.....?,_'-Garbage Grinder _,_ �_ r� -�--��- -------=--= ------ Water Supply: Public System and name .______.___�__-_�r�•�___ •---------Private «. Character of soil to a depth of 3 feet: Sand'D Silt ElClay ['Peat[] Sandy Loam ❑ Clay Loam ;❑ Hardpan ❑ Adobe [] Fill Material ------------ If yes,type----------------------------- N, (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 se er is:available within 200 feet,) PACKAGE TREATMENT ( ] SEPTIC TANK S •----�Ilc � Liquid Depth ,^ p0b P Q / �^ = Capacity/9 [� TYPe �" �- - •Material-: _.___ a*` No. Com artments Distance to.nearest: Well ___-- ----------------------•Foundation --------- ------.Prop. Line --- ---_-------= LEACHING LINE [�] No. of Li�5 _.--_---�----------- -- Length off-. ach. line-- -- --- -_--- Tota[ Lengths,-�__'„-_. -- -De .th Filter Material ___ - _____._ 'D' Box. _--_.__.---- T e Filter Material P ”' Yp Distance to nearest: Well ------------ ` _----- Foundation ___°� ______ - ---- Property Line _ ___._.---...:__-- SEEPAGE PIT ] Depth ._ _ -_.__ ___ Dia er _ ____ ..____ Number --------------- ----- ----ri Rock Filled r Yes No .� . y Water Table Depth - - - - -------=-----Rock Size ---; --- -------=-----°�` Distance to nearest: Well ---------------- Foundation ------- *' r �r : Prop. Line =-� ----- ` ------ Date -------------------------------------- - ----- ------ REPAIR/ADDITION(Prev. Sanitation Permit�# ----------------------------- �- ---------- --------.) . __--_____i y.._-v„__________________T Septic Tank (Specify Requirements) -------------------- ------------ --------------- - ---------- =------- -------- --.- --- ____ I Disposal Field (Specify Requirements) -----------_ r. ----------------------- ----------------- ----------------------------------- -------------------------------------------------------------- ------------------------------ ---------- ----- -- (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 Son 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 subi to Work an's mpensation laws of California.” Signed Owner , ------ Title -- ---------------- -- ' (If otUan owner) F FOR -DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ``---- . ----------------------- ----- DATE _.__ .-. J��------------------- BUILDING PERMIT ISSUED DATE ------- ----"-----------=---------------- ------- =------ -------------------- ADDITIONALCOMMENTS ---------------------- ------------------------------------------------------------------- ------ -- - k i --- -�'�-'1 : �'� - -- - ---:------------------------------------------------------------------------ --------------- -------------------------- • = -- --- .7.,7--� -Date ----- -------------------------------- Final Inspection by: ----- '�� i SAN JOAQUIN LOCAL HEALTH DISTRICT ` E. H. 9 1-'68 Rev. 5M.