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FOR OFFICE USE: APPLICATION FOR SANITATION .PERMIT Permit No; _�7Z-z (Complete in Triplicate) ------- ------------------------------------------------- - Date Issued This Permit Expires 1 Year From Date Issued ------------------------ _ Application is hereby made to the Sa -Joaquin'Local Health District for a per to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: .. -Sf - --'CENSUS TRACT' ------ JOB ADDRESS/L CAT10N _ - Phone Owner's Name ------- -- ---- - ` -1 City -- -----------------------------•-----••- Address 16�- Contractor's Name ------ ---- ------ -- ----------- ------------- - --------------------- �------.License # ---------:---- --------- Phone •-------- Installation will serve: Residence n Apartment House❑ Commercial ❑Trailer Court !❑ Motel ❑ Other --------------------------------------- Garba ---------------- ------- --- -=------- Number of living units:_-__�------ Number of bedrooms ___ _----... ge 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 jt5- 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 TANKpd Soe A& e----Z7 X—r— ---��---------"- ---- Liquid Depth ___ "-------------- Ca acit 2�------- T e -- - -'m o. Compartments -------- Dista _ .--- �� P Y � Yp �r-ems'-_ ater�al`�t��-�N Distance to nearest: Well -_ -------------------Foundation _.._ -------- Prop. Line _ .-.--------- LEACHING LINE No. of Lines ----/--- - ---------- Length of c li - pp� ------------- Total Length!/_----- a------------ D' Box .-'"'"'-_-- Type Filter Materia __-,• - ----)-A'D Filter Material--`-- -- --------------------------•-•-- � , r :\ Distance to nearest: Well -__ _ _______- Foundation ----- -------- Property Line ___�__________ SEEPAGE PIT Depth __._/0 _ Rock -Filled Yes [�No.___ __-- Diameter _ "_-- Number ------------- ------"""-- - A ___11r,f ' Rock Size ----�_:--!J-------- -------- �� Water Table Depth ----=----' �------f-------------=--•----- f , i Distance to nearest: Well _______77 --------------Foundation --------—Prop. Line ____ ____ __________ REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _________-------------------------) Septic Tank (Specify Requirements) -------------------- ------ Disposal Field (Specify Requirements) -"--- ------"------""""""""- --------------------------------------------- --------------------------------------------------------------=---------------------------------------------------------------------------- (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: "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 bec74rAA4A��- subject to Wor cman's Compensation laws of California." - Signed --------------------- - ---------------------------------- Owner i -, -------------------- ----------- ------------------------------------ -Title --------------------- (If other than owner) EPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ 1------------------------------ - -- ------------------ DATE -- -=�-�---------- BUILDINGPERMIT ISSUED __. ----- --------------------------------------------------=---------- DATE ADDITIONAL COMMENTS -------- - - - 7 --------------------*--------------------------------------------------------------------------------------------- ---------- •------- ----- ' -- --------------------------------� --- ---------------------- ------ ----------- ------ Final Inspection b -------------------------------------------- -------------------------------Date ------If7 17 ``----------------- SA JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-' 8 ev. 5M.