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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No. . ........ ..............................-_.......... (Complete in Triplicate •-•-•-----�-- ---0000---•..__......_ Date issued ..:5..`1S 7 This Permit Expires 1 Year From Date Issu Application is hereby made to themade corn liars Locallth Courict nty OrdinanceNo.No. 549 and exirmit to sting Rulesta(ndhRegulatons: rein described. This application_ is ma p _ / ..........CENSUS TRA 01-1-1............ JOB ADDREss/LocATION ......._ .. y ._...._... if/GT '/�-...... .. ••... � Owner's Name � ��. ltl .............. ........... Phone .. . Address . _ ... City .... Ph •lJ� � ...._ 1 f ... !�. .�` � ---.License # ... .. . ..... Phone �. . . Contractor's Name ..._l "' Installation will serve: Residence C]Apartment HouseWIC ❑Trailer Court Motel ❑Other . ....................................... Number of living units:- --0000. Number of bedrooms ............Garbage Grinder # -.•• 'Lot Size .. Private __ _ _ _ 0000.............•--................ Water Supply: Public S stem and name ......._....0000_..--- -.---- ••----.....---•••-•---•.......... �---]L-"' Clay Loam ❑ Character of soil to a depth of 3 feet: Sand'❑R Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Y Hardpan❑ Adobe '. Fill Material ............If yes,type ............... ............ (Plot plan, showing size of lot, location of system in relatf6p 4o wells, buildings, etc. must be planed on reverse side.) NEW INSTALLATION: (No septic tank or seepage pit permit ted'lf public sewer is available within 200 feet,} PACKAGE TREATMENT ( ] SEPTIC TANK I l Size............................................. Liquidp Capacity ---- --------------- Type .................... Material---------------------- No. Compartments ........--............rC Well .---•--- ........ .Foundation ........ Prop. Line ---......_. .......... Distance.to nearest. � LEACHING LINE No. of Lines -..-�_-••--�-••--�--- g Length of each line.------------- ............. Total Length -......................... ( � .- 'D' Box Type Filter Material Depth .Filter Material 00__00 ----- --__..._ Foundation Property Line ........................ Distance to nearest: Well-------------- - ---�..._.........-.,.... SEEPAGE PIT ( ( Depth ------------ Diameter . .-------•------- Number :_0000.............. Rock Filled Yes ❑ No �❑� Water Table Depth ............. ..................................Rock Size ........................ ----Foundation ............. .... Pro Line .._.............. � . Distance to nearest: Well ------------------•-•-------0000.._ ... p' .. Date ._..._... REPAIR/ADDITION Prev. Sanitation Permit�# ....................... -• _ - -•-------•-•--- Septic Tank (Specify Requirements) .................. ....------------------------------............................................._........-......... - Disposal Field (Specify Rfequire-m-e--nt_s) .-j1 -V- .7Xr ••--- . ---•----2 .. o7- ------------------------- .. _ -----------._..--' - -- - -------------------------------.-.---•-._---------------------------............................................ (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 th permit is issued, I shall not.employ any..person in such manner as to become subi�ert to or an's Compensa' la f a orniaEn Signed __.-: ._1 .. er -- 4i�l ... _I.....____. Title -- .. ------ ---------- ----------- By ----- ----------------- •--- -...- .... (If other than own 1 FOR DEPART NT USE ONLY / ? -----------------: APPLICATION ACCEPTED BY .. --•-------•------ DATE . � f --- - BUILDING PERMIT ISSUED ----0-------- - - ----------------------------- ---...0__0.00_._..- DAT 0000 ...-0_00__0. ADDITIONAL COMMENTS ------------- -------- ..._._____.. ........... ....................... ...........0000------•---------...------- ...... .-_ f '- ------------------------------------............. ....... ...........• - rx _...------ --"------------- --------• -•-•----- ---- ----- ------ . -- .. ........... final Inspection by: 00............ . .......... ...... ......... . ......... ------ .... Date ....... EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M