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FOR OFFICE USE:' F� 7� T71�ed;1eX1*L - / 7.7_ APPLICATION FOR'SANITATION PERMIT ---------0-----------------' ------ ---- -- (Complete in Triplicate) ----------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued --/-'_7=32-. 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: JOB ADDRESS/LOCATIO /- - -- -- -14---- --------- -- ---- -CENSUS TRACT -------------------------- f Owner's Name --- A---,-------- - --------- ---------------------------•------------------------- -----------r-------------------Phone ------------------------------------ Address ------ - --------------- ------- . city Address --------------------=---- /3r st7� e --- tY _ --•------ Name ------- T�% L ____-. ----�--------------License #�.6 _ Phone ---------- Contractor's ---------------- Installation will serve: Residence partment House,❑•Comme'rciat ❑Trailer Court i❑ i • �Y Motel ❑ Other - ------------ ------ -- ----- =---• Number'of living units:---_--7 Number of bedrooms ---i-7z_Garbage Grinder "- Lot Size -9 ��s_.__---__. Water Supply: Public System and name _ _ �<'"�` � --/�. ---'_ --------------Private Character of soil to a depth of 3 feet: Sand'❑ Sift❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam , Hardpan ❑ Adobe Fill Material __ __ If yes,type --------------_____-_-_-- (Pl'ot plan, showing size,of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) E NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � PACKAGE TREATMENT [ ] SEPTIC TAN S' e___ __ y ))_ �T l/' 2- � Liquid Depth -1 ..... Capacity) --- Type ----- Materia _ _ _____ o. Compartments -�Z�____.:__.. Distance to nearest: Well ------------------------------------Foundation __�Q_�_________ Prop. Line-S__________________ LEACHING LINE [ No. of Lines -----!------__---_-_ Length of ach line... 4 _.�--_.___ Total Length ` - --!.._...__. r'D'=Box ✓_ __ Type Filter Material G -_Depth Filter Material ------- -- ______________________________ Distance to nearer Well -____-_—_-_-_--- Foundation --�----__-_-- Property Line. __S__________________ SEEPAGE PIT Depth -_ -------- Diameter �j - --- Number ------_J--_---j-__-___--__ Rock Filled Yes No i❑ Water Table Depth i1 --------------Rock Size ..___-_--- Distance to nearest: Well ------------— --- _... Prop. Line -S--- --..____---- REPAIR./ADDITION(Prev. Sanitation Permit# -•------ ----------------------------------- Date ----------------------------------I SepticTank (Specify Requirements) ------------------ -------------------------------------------------------------------------------,----------------------------- Disposal Field (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------•-- ------------------------------------------ =-:-: ---------------- ----- -------------------------------------------------------------------------------------------- ----------------------------------- --------------------------------------------------- -------------------------- ----------------------------------------------------------- - (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, Siate taws, 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 anyperson in such marine# as to become subject to Workman's Compensation laws of California." r Signed ----------------------------_~- ------------------------------------ --------------------. Owner BY ------------------------------- -- -- �- `�-------- ------ Title ..__ �1: (If other than er `� �. 001t DEPARTMENT USE ONLY � ,BU LLD CATION A TCEPTED BY__ --� - ------------------------------------------ --------------------------------- DATE DATE .... ---- ----- --------------------------------- --------------------------------------------- ADDITIONAL COMMENTS --------------------------------------- - --------------------------------------------------------------------- ------ ------------------- Y -------------------------------------------------- ----- i J - Final Inspection by.. Date � SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. --- 1-'68 Rev. 5M