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FOR OFFICE USE: f APPLICATION FOR SANITATION PERMIT ......................../--jf�........ ..... Permit No. T..r-�..-�_�,.,3,. t (Complete In Triplicate) . .................... This Permit Expires 1 Year From Date Issued Date Issued ... ...-....`...sir 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: J08 ADDRESS/LOCATIO }....-:..� ---.� w.. ........................ .........CENSUS TRACT ......_.. ................ Owner's Name ........ .. ............................ ................................ Address ---•-�-.._._.._...-__••••_.... City :: �.... .. ...... �...._ . Contractor's Name ------- # - ''I-`�?°'� Phone Installation will serve: Residence*Apartment House❑ Commercial ❑Trailer Court 0 Motel ❑Other ............................................ Number of living units:-..--l.._._ Number of bedrooms _.'2!7:...Garbage Grinder Lot Size .X-2�7,� fs.��............... Water Supply: Public System and name --... :<!-fid- ............ ...........................................Private ❑ Character of soil to a depth of 3 feet: Sand n Silt❑ Clay ❑ Peat 0 Sandy Loam ❑ Clay Loam 0 Hardpan ❑ AdobeA 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,J PACKAGE TREATMENT SEPTIC TANK f J 65L-A-fX' 7—'-f ae.__ --------------------------------------- Liquid Depth .... --------------------- Capacity ---- --------------- Type -------------------- Material...................... No. Compartments ..................... Distance to nearest: Well ....................................Foundation ---------------------- Prop. Line --•---;...........•_).J LEACHING LINE V No. of Lines ...... _____________ Length of each line----X-a-_..__._.___... Total Length .. - ..............00. 'D' Box ... Type Filter Material ....Depth Filter Material .-.,1.�..`...� ..............I......... � Distance to nearest: Well Foundation Property Line ..:�......_.._........,.. SEEPAGE PIT ` Depth '_..._.. Diameter .. .-,5Number ..../.................... Rock Filled Yes 0 No ❑O Water Table Depth , r ._Rock Size Z_.` r Distance to nearest: Well ... :.fes_ --41 ... ...........Foundation _..04 ......... Prop. Line :� -------------- .e REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date _.__.._.-_ ....................... Septic Tank (Specify Requirements) .......... ....... ..........- •-. ---------- ---- --- ---- _., .............. Disposal Field ISpeeify Requirements) .............. .��-------------.� !X�acs ........ . ---••--------------------------------------------------------• •-- ...... ........... ................ . e ............................................................... ......._..----------........................ - !-.. (Draw existing and required 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. 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 subject to Workman's Compensation laws of California." Signed ........ ....................•••-...-... ...... -•---- ................................ Owner By ........... -aA41"'14 - -------------------------------- Title . �r�..� .............. (if other than owner / OR D!fAR1MgNT USE ONLY APPLICATION ACCEPTED ._ DATE f.__.---__ ---------•------------ -- BUILDINGPERMIT ISSUED ..................... ..........................................-..........................DATE ........................................... ADDITIONAL COMMENTS ......... .... .......--•-- ` . . . . ::: ::............................................................:...........-....... ......................................................... ..............V..................-----•-•-.........._.__.......--•--...._....--------------••----•-----.......--------•-------------------•-•••--------------- -------------- .................... --- ---------- ----------------------- /~ � --Date . Fina( Inspection by: _. - --- - --� '"'��--........--•---•-•...................••------•--•---- -Ee•/. - .- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.1-3 24 1-'68 Rev. 5M_ 7/723 ,14