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rUX OFFICE USE: APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit N This Permff'l=xlStrss 1 Year From Date issued Date Issued .'/.`.� 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 mgde��omp�anc�,h County Ordinnce No, 549 and existing Rules and RegulationsJOB ADDRESS/LOCA TION _....._//....//--/.....................i _ . ... _ -.. ._.. ........._CENSUS TRACT ...... ......... Owner's Name .. n'- lf. ��N .. . _ .►� _ �._:��.N1rl......-�---. ..� �,c.,:.............. ..._.f-rr Phone 5�:�-, of - Address ....,_. ._... .._ _T-�'c��crr_1_._....--•- City P. ----------•---•- ......---- --•................ .. ....................................................• Contractor's Named -�---- -------•--•.license # ----- .....__ Phone ..--------- . ....----- . ................ Installation will serve: Residence&]Apartment House❑ Commercial❑Trailer Court Mote! ❑Other-------------------------- Number -----------•------------Number of living units_____________ Number of bedrooms ..... --_Garbage Grinder _.-_-_-____ Lot Size ......................... Water Supply: Public System and name --------- .................... ---•--- _-_--•........Private b Character of soil to a depth of 3 feet: Sand 1-1 Sift❑ Clay.�; Peat❑ Sandy Loam fl Clay Loam D Hardpan❑ Adobe Fill Mpterjal ----------_, ty ❑ If yes, pe ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be planed on reverse side.) NEW INSTALLATION. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,# PACKAGE TREATMENT [ ] SEPTIC TANKSize------- ---------•---•-•-•-•-•------ ---___ Liquid Depth ......................... � l ------- 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 ...... PIT [ J -------------------- Diameter ---.....------ SEEPAGE,._ Depth _ Number .---•-------------------•_-- Rock Filled Yes ❑ No i❑ Water Table Depth ----•-- --------------..........................Rock Size __- ............................ j Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ............................ Septic Tank (Specify Requirements) ............... ....... . .... .. ..... -• ................................... Disposal Fielc( (Specify R uirements) �. � _. _ f� �a c .-_._� �lcr.....�GG'Da_.. ..._...._. :.. �._�-..._tea ..................------.-•------------------------------------------------------------------------ •---------- (Draw existing and required addition on reverse 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, I shall not employ any person in such manner j as to become subject to W rkman's Compensation laws of California." Signed �----------------- ----- Owner B Y ---------------------------------------•-------. Title ................ ............. ---- other than owner) _ FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY .____.. ..---- --------•--------- -- ----- -------------- • ---- DATE 7-7 PERMIT ISSUED ----------- --•----• - DATE ADDITIONAL COMMENTS . .fie._ ---•------------------- ---- --. .-. .......... •-- • -------- --•-- ------------- ------•-•- ............ -•---• ----- ----------------- nspection by: ___-••-- - Date ........ 24 1-68 Rev. 5mSAN JOAQUIN LOCAL �Hi ALTH DISTRICT 8/711 3M