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FOR OFFICE USE: Zf j�Z? �. 5-f23 1030 AM APPLICATION FOR SANITATION PERMIT -------------- --J-----=-------,•-------- ---- -- Permit No. " I X3 bo {Complete in Triplicate} -------------- --------- - ------ --- ---------------------- " � Date Issued 4g--- _. _-- _______________ This Permit Expires T Year From Date Issued Application is hereby made to.the Sari 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/LOCATION'. _17- tit -----�ZO-- a - CENSUS TRACT -------------- ----------- Owner's Name Phone Address ------��- t x=- _- _City i Contractor's Name ------- -------------- -- - ��•C---�'"'-"""-----------•-=--------License#117.e ----- I'hone4i-47a------7.----• Installation will serve. Residence [�artment House-F] Commercial ❑Trailer Court Motel ❑Other --------------------------- ---- Number of living units__________ Number of bedrooms 3-------Garbage GrinderJ-06 ___ Lot Size _ l �S_x_. ..a _______--Water Supply: Public System and name --------------------------------•---"---------------- -- - ------------------------------------Private [ . Character of soil to a depth of 3 feet: Sand b Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ ,. Hardpan ❑ Adobe'Ej Fill Material ------------ If,yes, type ________________ I (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 eY c�s -------- ------- Liquid Depth a r� Capacity _i°-OOest: Type;�a.�%____ MaterialCr� No. Compartments �_... :_ ,= Distance to neaWell ---7Q--_------------------- ____•Foundation JO_a-_-________- prop. Line `d_._--__.___._. LEACHING LINE [► No. of Lines __-4Z--------•------- Length of each line----:7-------------------- Total Length -__ ____.._________ 'D' Box1_V_+��—Q-- Type Filter Material _17414�------Depth Filter Material __fe______________________------ --- Distance to nearest. Well _______________________ Foundation ---------------- Property Line. r'`r ___._--.__._._.___ SEEPAGE'PIT,_ [. Depth _ S -__ Diameter - 3- :°"' "Number -------- -------- Rock Filled Yes ®--�No i❑ a • Water Table Depth __ _D__-_-___- _____________ _______Rock Size _�_�__ Distance to nearest: Well _ ________________•__.,•_ ___-_Foundation --____.___.- Prop. Line __�----____----____ REPAIR/ADDITION{Prev. Sanitation Permit# -----.---------------------------------------- Date -----------.----------------------) Septic Tank (Specify Requirements) -----------------------------------------------------' Disposal Field (Specify Requirements) --_.':._-__ "i -----------------------------------------------------------------------"------= -------------------------------------- ---------------------------------------------------------"-------------------------------------------------------------------------------------------------------------------------=------------------------ 1 ------------------------------------------------ . • (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: k "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 subject to Workman's Compensation laws of California." Signed - ------------------------------------•--. Owner -------- -- --- - - - BY -- 4 - --- - - - -------------------------- -Title ----- --------------------- - ------------------------------------ (If other t n owner) I FOR DEPARTMENT USE ONLY ? APPLICATION ACCEPTED BY k��:_ � 1� _------------------------------------------------------------- II eF" BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ --------------DATE -------------------- -- ---- ------ ADDITIONAL COMMENTS - ----------------------- ------- ------------I---------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ --------------------------------- -------------------------------------------- ----------------------------------- ----------------------------------------------------------• ----------------------•---- ------------------------------------------------------------- Final Inspection by- --------------- ------ ------------Date -- - - ----------------------------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M