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FOR OFF u = _' r'4 ICE USE: APPLICATION FOR SANITATIQ�+I 'PE�VIIIT Permit Na: " -- ---------'------ ;� ----------- --------------------- ------------- (Complete in Triplicate) -------•----- •---------------- Date Issued -?'-`�_�-�� . -- Expires 1 Year From Date Issued -------------- This Permit Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein with County Ordinance No. 549 and existing Rules and Regulations: described. This application is made in compliance ! `/ JOB ADDRESS/LOCATION . �I�- l --------/Y-�- --- - 4 ------- ---CENSUS TRACT _// =_` .-------/- �+�}! - - Phone --�67"_-_3 3.3� Owner's Name ----� i �` ----- - r`"--------- � City - -� -------------------------------------------- Address , ---- -------------=---- ----- - -------- ----=---- --------------------- � _ _ License # - Phone Contractor's Name ----- /`� nce - Installation will serve: Reside 'Apartment House❑ Commercial❑Trailer Court 0 � Motel ❑Other ------------------------------•------------- Number of living units:_________ Number of bedrooms __- _--Garbage Grinder __"`r___ Lot Size - 6- -- Water Supply: Public System and name -------------------------------------------------------------- ---------------------•- -------------------------- - ----- ----------------------------------•L- .Private Peat Sand Loam K Clay Loam Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ ❑ Y Hardpan ❑ Adobe,0 Fill Material ------------ if yes,type ----------------------- - Plot Ian, showing size of lot, location of system in relation to- wells, buildings, etc. must be placed on reverse side.] �a { P NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) //� `i Size ----- ------------ Liquid Depth 12^� -----.---- ; PACKAGE TREATMENT { ] SEPTIC TANK - - - --- - -" Capacity J � Type _I ' CjMaterial-_-- No. Compartments -- ..- ---=---- P Y ----- �� f -- Pro Line --_----- Foundation ___ __ ___________ p- Distance to nearest: Well __ �------------------------ � / __�[--___ Length of each line_______ Tota! Length ---- .- a LEACHING LINE [ ] No. of Lines -------- -------""I " "" aa ; 'D' BoxK TYPe Filter Material -C---- Filter Material _—Y- ------------------r------ Distance to nearest: Well __��"__�"-- Foundation ___ - ---"- -•- ------- Property Line _ ------- --- --------------- Diameter------------------ Number ---- .---=------- ---------- Rock Filled Yes ❑ No 0 SEEPAGE PIT [ ] Depth " Water Table Depth Rock Size ________---------------- ----- Distance to nearest: Well ------------------------------------------•-------Foundation -------------------- Prop. Line _.-------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------- , - - -------- -------- -------------------- i Septic Tank {Specify Requirements)--------------------- ------- -- ----- , Disposal Field (Specify Requirements) -_- --�__-- ------ _ 1----- ----------------- ----------- -------------- ------------- -------- -- _-----_ j �--�S_-e_�___ _______________________________________ _-__-_.._-.._ -------_------------- _ (Draw existing and required addition on reverse side) I hereby certify th 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 performance of t e work for which this permit is issued, 1 shall not employ any person in such manner as to bet m _b-1t' to Workman's pensati.on laws of California." Signed ' - -------------- - Owner ---------------------------- -- Title --------------------------------------------- } (If other than owner) F fR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ---- -------------------�-------- DATE k BUILDING PERMIT ISSUED -- ----------------------------------------------- -------------------------------------------------- DATE ------------- ----------------------------- ADDITIONAL COMMENTS -------------------- ------------------- -------------- ------___ ___ ::::_:____________:_______ _---------------------------------------___ ____ :: ___::: ______ ______ ________ ::________ : :_______ __________:::______� ::�_ _ ------------ ------- -- -- -- - - -- ------- - ate _.------- Final Inspection by: ------------------------------------------------ SAN -------- ------ --- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M. -