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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT p (Complete in Triplicate) Permit No. ................ ... ...................... ................ ................. This Permit Expires 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 made in compliance with County Ordinance No, 549 and existing Rules and Regulations: ._ _ . .: r � 3_ .1JOB ADDRESS/LOCATION � .__;{.. . . _ ............. .. _ _- .... �--• .........CENSUS TRACT ..... ................... Owners Name ..Phone Address ......... _.G .... .3.--...-fir .....--------------------------------------...........City .._. ._. ............_..._..--............................................. Contractor's Name ....> .A..Fu.�.h -----•......................••-•----•-........__.License # .."_57_5792 Phone Installation will serve- Residence [V Apartment House 0 Commercial ❑Trailer Court 0 Motel ❑Other ..................------------- Number of living units:....A...... Number of bedrooms_-.2.._-.Garbage Grinder ............ Lot Size ............................................ Water Supply: Public System and name ..............f.........................•-•---------•-----.........•••-•------•------....---•-...--••-•------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Cloy Loam' Hardpan Adobe Fill Material ............ If yes,type _-. o` U11 (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 -�X ` f � � Size....------•--�------�.��..........-------- Liquid Depth .... ............. Capacity .-]Q_X.P..... Type Pv� 35�Material.. _ cY4�CNo. Compartments ............ Distance to nearest. Well ...........!P0...................Foundation . 1.4f ............. Prop. Line ....1..4_.x':........ LEACHING LINE No. of Lines ..... " _... Length of each line..........41.0.r.......... Total Length -...! 4..`............. R lot D' Box ._:,f_..:..*Type Filter Material S�?L.! ......Depth Filter Material ..........!.d*....................•-.---•- Distance to-nearest: Well .../b§.............. Foundation ....l.'5'f ..._.------ Property Line ...�a�---•.......... �( I. SEEPAGE PIT (j Depth ---- Diameter ---.3.3...... Number ............................ Rock Filled Yes q No I❑ • Water Table Depth1.!. .............. ..Rock Sid_Z._.1_'.7..........•........ Distance to nearest: Well ........I...................Foundation .. Q........... Prop. Line :............. REPAIR/ADDITION(Prev. Sanitation Permit# ........................................... Date ..................................) SepticTank (Specify Requirements) -------•......................-............................................................................................................ Disposal Field (Specify Requirements) ..................................................................................................................................... --------------------------........................................................... --------.................. -----------------------.-...............................,................... (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, 1 shall not employ any person in such manner as to become sub' ct t Work n's Compensation laws of California." Signed ._ xX7 . S �.......... .� ...--•...I............. Owner - By ........................................... . . . . ........... title .................................. (If other than owner) -FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . . ...... ..... .. . .. . ..-...........................---..........•-----------.. DATE ..a'. .7 .............. BUILDINGPERMIT ISSUED ......-•--•..................•--•-•----. --.•...................------------------•••--.........I.....----DATE ..........................•----.. ...... ADDITIONAL COMMENTS .....................•...................... .. ....... ......... ................................ ...............................................,......--•••......._...-•--•-•------•-............-•-•-•-••.........---•------------•... ..................................... ...-----...... -------- �.. . Fina Inspection by .......Date c� � .:.._ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.13 241•'68 Rev. 5M 7/72 3 M