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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT --- --- 4. ----AI ' (Complete in Triplicate) Permit No. _____ --________. --------------- - ------ This Permit Expires 1 Year From Date Issued------------ 0 Date Issued�� --7 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 Regulations: JOB ADDRESS/LOCAT Z2__ ----------------------------CENSUS TRACT Owner's Name ____- � � �l --------------------------------------------------- ------------------ Phone - - t Address ------ _ ------------------------------------------------------------------•--. Cit Contractor's Name ------11�4 Z'-1 --------------------- ------------------------------ ------.License # ---------------------- Phone Installation will serve: Residence a partment House[] Commercial ❑Trailer Court i❑ Motel ❑Other - - - i Number of living units:---\------- Number of bedrooms __.....Garbage Grinder -0 6-- Lot Size '2-10-) 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 ❑ 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 TANK [ ] Size------------------------ ----------------------- Liquid Depth ---------------- - z Capacity -------------------- Type -------------------- Material---------------------- No. Compartments �I Distance to nearest: Well _-________ _ _ - - ----------------------Foundation ---------------------- Prop. Line ------------- ----•--- LEAC ING LINE L,.}- No. of Lines ---------I-------------- Length of each line_________ __ L?"Q-�_-_-- Total Length ------I__fI`C)........... }� 'D' Box _-]------- Type Filter Material __________________Depth Filter Material Distance to nearest: Well ____________ __ -_-------•_---•---�----•--- ___ -___ Foundation Property Line ------------------------ SEEPAGE PIT [4-00 Depth �" __ _____ Diameter __ _._-_ r p ----- - ______ Rock Filled Yes ®� No i❑ - Number - ------�--- -------- Water Table Depth --------- --------------------------------------Rock Size ------- Distance to nearest: Well ___________________________________ ___Foundation -------------------- Prop. Line ---------------_--- REPAIR/ADDITION(Prev. Sanitation Permit# __________________ -------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ---------------------------------------------------------------- -------------------------- isposal Field (Specify Requirements) --------------------------------------------------------------------------------------- ----------------------------------------------------------------=----------•------------ ------ - - - -- ------------------------------------------------------------------------------- - --- ______ _ (Draw existing and required addition on reverse side) I hereby certify that 1 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 become auto W Arkman's Compensation laws of California." Signe �•-�r- ---------------------------------- --- - Z=' -='t - '------------------------- Owner ------------------(If__o------_t - -------------- Byn ---------------------------------------------------- Title .---------------------------------------------------------------------- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _________ _ , _ -------------------------------------------------------- BUILDING PERMIT ISSUED ----------------------- - ------- DATE __-- -_�__v____------ --------- . - - - DATE _ ADDITIONAL COMMENTS --------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- -------------------------------- ------� --- - -- - - --- ------------------------------------ - -------- Final Ins ection b -- - --------- -A ------------------------------- p Y -------- --- ------- ------------------------------Date !/ SAN JOAQUI LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M