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FOR OFFICE USE: ia3 G —3�a API'LICAT)ON FOR SANITATION PERMIT 3 Permit No. (Complete in Triplicate) --------------- This Permit Expires 1 Year From Date Issued Date Issued67-9_= ._ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein i i described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: l JOB ADDRESS/LOCATION ._ ® iJ --------------•---------------CENSUS TRACT --------------------•----- Owner's Name -------- ----------------------------- -------------------Phone ---------------------------- ----- I Address ---- --------- ----- �__d- F--------------------------------.--. City ----------------------------------------------- - - Contractor's Name �f = ------- --------.License# fes: o�5 ne a>Z Installation will serve: Residence 14k-p-artment House,❑ Commercial:❑Trailer Court ❑ ) Motel ❑Other --------------------- Number of living units:---- Number of bed ooms ;__ Gar age Grinder _ _.s?4___ Lot size _��/.-__�-------------------- Water --� ....___ - Water Supply: Public System and name -_--____- x- -i__.__---- ----------------------------------------------------------Private ❑.w i Character of soil to a depth of 3 feet: Sand'[] Silt E] Clay Q Peat E] Sandy A,-Loom ❑ Clay Loam .F ' Hardpan ❑ Adobe ill Material ___ 1.�_ If yes;type ____________________________ {Plot plan, showing size of lot, location of system in relation to wells, buildings, .etcr must be placed on reverses)de.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available'Within 200,feet,)"`—'> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size_____________________________ __*.__ Liquid Depth --------------_4"-----__- ,J Capacity . Type _________________--- Material------------------ No. Compartments T__________ Distance to nebrest:..Wel1 ------------------------------------Foundation --------------.Prop. Line�---�-----__r_ _.,._ .--•- I- y. LEACHING LINE C [ ] No. of Lines --J--------------------- Length of.each line__________________r__r a__ Total Length _______.,:_F^_, D's Box ----------- Type Filter Material --------------------Depth Filter Aaterial ------------- - __ ______ "__' _ -'..___,_ i �Ir Distance to. nearest: Well ________________________ Foundation ------------------------ Property Line .___________. -__._ __ SEEPA& PIT Depth ____ _ _____ ______ Diameter --__-__________ Number ___ -______-- __________ Rock` Filled Yes ❑ Na 0 .` Water Table Depth = ' = Rock'Size ---------------- Distance tonearest: T nea rest: Well ---------------------- A--------- ----Foundation s, --- ------- Prop. Line ---------------------- REPAIR/ADDITION-(Prev.-•Sanitation Permit# _________________ _ . ' � '-Date ) ------------------ Septic Tank (Specify Requirements) ------------------ ----------- ------ --------yr.,. yr W Disposal Field (Specify Requirements) ____________ _ �� ------------ -- _ -------------------------------------------------- ----------------------=------------------------ I (Draw existing and required addition on reverse side) i I hereby certify that I have prepared this application and that the work)will be done in cccordance 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,..-. empl y any person in such manner as to become subject to Workman's Compensation laws of California." f r Signed ------ ---------------------------------------- - ----------------- Owner ' -- 2------- By ------------------ ------------------------------- Title -- - ----- ---------------- [If other than owner � -----+- ------------ - FOR .DEPARTMENT USE ONLY, APPLICATION ACCEPTED BY ---------------W- Q _tri.P DATE g BUILDING PERMIT ISSUED ----------------------------------------------------------------- -7---------------DATE A ADDITIONAL COMMENTS ---------------------------------- -------------------- ----------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ---------------------------- -------------- --------------------- - y----------------- -- Final Inspection by: - ? Date y ' ---------- - -- -- --- a y- l SAN JOAQUIN LOCAL\HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.