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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ permit Na. ...-,7 - . S '? 4 lComplete In Triplicate} ............... ................................... .......................................... This PermitExpires t Year From DatelsswDate Issuedd ... 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 Rogulotionss JOB ADDRfSSAOCA IRON _ CENSUS TRACT Owner's Name _..4 %% _ .'/ t.f.............. .'..................._.. .. .... Address J �_. �- '� ty Oe% ---• ---••- Ct Contractor's Name . -�, .�v...: c T ,w �._...- t.:C.:--..Liconse # � c�, .Ff. -Phone .............................. Installation will serve: Residence rtment House Commercial OTrallor Court 0 Motel ❑Other........................................... .-. I-- . Number of bedrooms � Garbage Grinder ............ �- Number of living units: - -_-- ... ....._ Lot Size ......................... ............... Water Supply: Public System and name ................................................................ ❑-`` ..............................................Private Character of soil to a depth of 3 feat: Sand D Silt❑ Cloy ❑ Peat❑ Sandy Loam 0- Clay Loam❑ Hardpan[]___,Adobe 0 Fill Motorial ............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 TANK ii ) .. Liquid Depth 17 Size.............................................. .......................... Capacity --------------•----- Type .................... Material...................... No. Compartments ...................... Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE [ j No. of Lines ------------------------ Length of each line............................. Total length ............................ 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest; Well ........................ Foundation ........................ Property Line ........................ SEEPAGE PIT [ ) Depth ----- .......... Diameter ................ Number ......... .................. Rock Filled Yes ❑ No Water Table Depth -•....................••-------------••--•......Rock Size ................................ Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION#Prov. Sanitation Permit# ............................................ Date .................................. SepticTank (Specify Requirements) ..................... • • ....... ............... .............................._............... ....................................... Disposal Field (Specify Requir en } .l �C l o_ ..._ (!. —.. t�.-- � �,, _ „ _ � . = ------- ------ ......-_..................•..---•--------...............----...._.......................-•-......... (Draw existing ondired addition on reverse side) 1 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. Hence ewr w or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to Workman' Compensation laws California." Signed __... -�••..... ...... . .... ..... ....... Owner By ----- .._._.--- (If other than ow FOR DEPARTMENT uSE oNIY APPLICATION ACCEPTED BY ----- ----- . DATE _.Li 'l ......BUILDING PERMIT ISSUED •--...---•...... DATE ._............. .._.....----•• -••••-•...... --- ................ ADDITIONAL COMMENTS ...--------- ........................ ----------- ------ -----------------:,-------•-- ......................................_--.----.----------- ............. .......... .....-----_. -- ------------------- ---------------------- ----------------------•----- .........--........-- --.......--- ......--------.._......----••......--•--- ---- --------- ---------------- ---------••----•• • •--..._.................... •• - _ ...........•-•-•--•-•-•. ----..........-- ---- - -... _......... . Final Inspection by: ----..._.G'..--- ...Date . ...................• .-- EH 13 2h 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7b 3M