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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT i ---- Permit No. gg--�_L "_��U (Complete in Triplicate) / ---------=---------- ---------------------- _-__----_- f Date Issued __ _(--��----- ------- ---------------------------- ------ This Permit Expires 1 Year From Rate Issued Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein x fin compliance 'th County{ Ordinance No. 549 and existing Rules=and'Regulation described. This application is made --CENSUS TRACT -----'-------------------- JOB ADDRESS/LOCA. ON 0./�--- --- - t -- l----------- Phone ------------------------------------- Owner's Name _ - ' -.Lice ' Address _ `�-- --- --- ------ ------- ` i ( - Contractor's Name -------- - ---- ----- f.-------- ---------." r= Phone Installation will serve: Residence Apartment House Commercial :❑Trailer Court ❑ r i Motel ❑Other -------------------------------------- ---- �72 Number of living units:------/--- Number of bedrooms -�-_-------Garbage Grinder _- .- Lot Size "�_- ---- ----,- Private Water Supply: Public System and name _____-_-__ "---"---"- - ------- ------------ -- - ilt Cla Peat Sand Loam .❑ Clay Loam Character of soil to a depth of 3 feet: Sand'❑ ❑ Y ❑ ❑ Y Hardpan Adobe'❑ Fill Material ............ If yes,type ------------------------- ! buildings, etc. must be placed on revers amide.) (Piot plan, showing size of lot, location of system in relaiion to wells, / NEW INSTALLATION: [No septic tank or seepa -pit permitted if public sewer available within 200 feet,] Sizey/ - -'r" - Liquid Depth _'�� ---------- --------- No.TREATMENT [ ] SEPTIC TANK'[ ------------ ------ -------- Ca acit 1 � _ Type _ - Material: 6 No. Compartments ----- ----.•-/--- P Y -G__------ Pro Line - j istance to Weare Well __________ _ _ Foundation ----�- f p i � - r c J .....,v-� -� LEACHING LINE [ No. of LI -------------- Length of each line__--- - ---[- `Totangth/.__ ----`--- ` . 'D' Box _----- Type Filter Materials R_A,Depth Filter, Material ____��-----'- - 4?---____.-_ Pro er Line -_'--'� ---- - � Distancenearest: Well __" �f----------- Foundation __._l____ p tY > z rr c�__"_ ___-- Rock Filled Yes No..[3t I` SEEPAGE PIT Depth _ . ...""--"" Diameter __--------- Number ------------ -- --- .� �n Water Table Depth ------------------- ---------------- __.Rock Size _ _ - — ------ Foundation 0- / I f � - ---- Prop. Line ------- ----•------- kDistance to nearest: Well ____.-____._"`¢4-"_" REPAIR/ADDITION(Prev. Sanitation -------- ----------------------------------- ) Date -------:-'`�"�--�" ------ I v r Septic Tank (Specify Requirements) ------------------- ------------------------------ Disposal Field (Specify Requirements) - - - - - - ----- ------ -------- •------- --- z -----k---_________________________ ------------------- ----------------______ "" �. _________________ _________ ____________________________________________------ -------------------------------"�"_. ---------------_- __------------- ----- -- -------------- •._ _____________- •[brave 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: f, "I certify that in the perforn such manner mance�of the work for which thls�permit is issued, I shall not employ any person I as to become subjectt or man's Compensation �Cal'fornia-" ._. . Owner Signed . -------- ---- 4�r✓ . rJ}QTitle (If other than ownei) ' FOR D PARTMENT USE ONLY P 11 APPLICATION ACCEPTED BY . - _ DATE _ --- � ---- - -- - - --- ---------------------------------- BUILDING PERMIT ISSUED ---------I-' -------------- --------------DATE ------------------ - -------------------------- ------------------------------ ------------------- COMMENTS ---------- --------- ------------------ -------------------------------------------- ----------------------------------------------- i ------------------------- ------- ----------------- ------------ ----- ------ ------ ----------------------------- _ --- - --- ---------- ------- --- --- --- -- Date"" - -------------------------------- ------- -- ---------- ------------ Final Inspection by SAN JOAQUIN LOCAL HEALTH DISTRICT ! E. H. 9 1-'68 Rev. 5M.