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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ......... ..........................-....._.-------•----- Permit No. O.� ... (Complete in Triplicate) .............................I.............. M i . This Permit Expires 1 Year from Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a per 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/LOCATION ,.....,- F �Jr.. _ ...-_...- !! lT�... .--.- - - -- . ...............CENSUS TRACT .... ._ .. �AI Owner's Name ......r-- A Y' Q/x. .�i. ,.. .......Phone ....... . Address ........... 1 ........................................................................ City ...........................................-...................- ....... Contractor's Name License # -.. Phone "` 5 -•------•--...----•---------------•-- -- . ......... Installation will serve: Residence [] Apartment Nouse C❑ Commercial ❑Trailer Court 0 Motel ❑Other .............. ....................... Number of living units------------- Number of,bedrooms ............Garbage Grinder ............ Lot Size .__.... ........... Water Supply: Public System and name .............. ..._.` ...:Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ ' Peat❑ Sandy Loam {] Clay loam ❑ k Hardpan El Adobe El Fill Material ............ If yes,type --------------------------_ (Plot plan, showing size of lot, location of.system in relation to wells, buildings, etc. must be. placed on reverse F NEW INSTALLATION:,, - (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) [ .... OQ PACKAGE TREATMENT SEPTIC T �/ � Size................•---.---............... ------- Liquid Depth ..--•••----••-•........ ._ 1 'Capacity -- ape ..............w----- Material.-- .................. No. Compartments --- --.I.:_............. Distance to nearest. Well ____________________________________Foundation _._..- ............... Prop. Line _----_--------- LEACHING ._._____ -------LEACHING )_INE No. of Lines ........................ Length of each line............................ Total Length .............. 'D' Box ............ Type Filter Material ...................:Depth Filter Material ..................-.:................... Distance to nearest: Well ........................ Foundation ........__... .......... Property Line ........ Rock Filled es :No ( L ) "Depth ....-...�..�. Diameter ..... Number = r ❑ ❑ Water Table Depth ----- ------------------- ....................Rock Size J x �a i Distance to nearest: Well ._,lQ4----_/-----------------Foundation ... �.a...... Prop. line ---....--_...::.... k REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .............. .................. Septic Tank (Specify Requirements) ---- - '.,... T.............-----_................. Disposal Field (Specify Requirements) ...........12ad... ... ---------- � -------- s ! .............:..._-.- = -------------------------------•.....--._...........__...---........u......... ............... (Draw existing,and required addition on reverse I de) I hereby certify that I have prepared this opplicat on 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. Horne owner or €icen- 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 as to become subject to orkman`:s?mp nsation laws of California." Signed Owner .... .. ............. •-------------------: itle ..:..........................................::.._.......:....:--------- (if ----- -•if other than,owner) _ /' `• F2gDEPARTME USE ONLY APPLICATION ACCEPTED BY . ...............••-••.. ..... ......................_. DATE ..7....-,S- ............. BUILDING PERMITIISSUED..................t_ ....... ..... •-- ----• -- . ....._..-....-...--••..........DATE ................................... -.._. ..,_. ADDITIONAL COMMENTS ........:.....•••-....- ...............-•-------------------•-•--_............I.......... ................................... ................. . ......... _ ._.. •. _ _... ...................I............. _.___ -.. .. .. {�- Final Inspection by. .....................................................Date .. ..._.j... SAN JOAQUIN LOCAL HEALTH DISTRICT n w € E. H.13 24 1-'68 Rev. 5M 7/72 3 M