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I. FOR OFFICE USE: APPLICATIQN FOR SANITATION PERMIT �� _5�3 r + y Permit No. ------------------- �--� (Co�rnpaete in Triplicate) --- - ---------------h---- Date Issued � _ ------------ -------- b <r __._____________________ ______________-____ This Permit Expires 1 Ygar Frotg Date Issued Application is hereby made to the-IS an aquin Local Health District for a permit to construct and install the work herein d i bed Thiikagpli }�jn is made c Ii nce with County Ordinance No. 549 and existing Rules Regulations: 55 ��/% JOB ADDRESS/LOCA _ ; L-d'�� . -lL� NSUS TRACT Owner's Name , ✓ - - ------------ ------- Phone 1 // - .mac./ Address -------------� ------ 4� �:K City t C� �---7- / Contractor's Name -------- � - License #` 2;5pL-__ Phone' Installation will serve: Residence partment House,❑ Commercial ❑Trailer Court Motel ❑Other --- -------------- -------------- _ Number of living units:--__ --- Number of bedroom-,.�_�_ _____Garbage GrindeLot Size _� ------- ---------- Water ._-Water Supply: Public System and name ------------------------------------------------------------- Private Character of soil to a depth of 3 feet: Sand'[] Silt E] Clay ❑ Peat E] Sandy Loam E] Clay Loam Hardpan ❑ Adobe V Fill Material 144?_ If yes, type ---------------------------- (Plot ___________-__-________(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,) O� . r. /. 1l ,, [ �` - Liquid De PACKAGE TREATMENT SEPTIC TANK Size__ pth W Capacity/„ ____,__ Type-, __ Material_ ------- No. Compartments ___2--------------- Distance to nearest: Well _______-- /--___---_-_____Foundation °G%'f______prop. Line __ ...... ` LEACHING LINE [ No. of Lines ---,, ----------------- Length of each line----go----------------- Total Length _24W'.............. D' Box }� ___ Type Filter Material _Depth Filter Materia6 -0--------------------- --------------•---- Distance to nearest: Well _...0(?------------- Foundation __,/4;i._------------ Property Line __,2 _.._•._.._-___ SEEPAGE PIT/40 Depth Diameter ______________ Number ------- Rock Filled Yes E-] No i❑ Water Table Depth ------------------------------------------------Rock Size ___________________ Distance to nearest: Well ______________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-_____-___.-______________) Septic Tank (Specify Requirements) ------------------------------------------------------------------ ------ -----------------------•---------------------------- Disposal Field (Specify Requirements) ----------------------------------------------------------------------- -------------------------------------------- --------------- -------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- -------------------- --------------------------------------------------------- ----------. -------------_------- (Draw,gzjstin-- q and re wired addition-on ieveise 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, 1 shall not employ any person in such manner as to become subject to Workman's Compensation laws of California." Signe -- ------------------------------------------------------------------- Owner 6 BY - - - Tjtle /--------------- -------- ---------------- (If er than owner) FOR .DEPARTMENT USE- ONLY APPLICATION ACCEPTED BY --- ----------------------=---------------------------------. DATE --- � � BUILDING PERMIT ISSUED --------- ______________DATE _ ----------.-----------._____.__-______- ADDITIONALCOMMENTS .----------------------------------------------------------------- ------ -------------------------------------------------------=---------------- ---------- --- --------------------------------------- -- - ----- -- j --- -------------------------------------- -- - --- -- ✓Fina - _ l Inspection by: - ----------------------------------- - ---- - --- --- --------- Date ------ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M