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FOR OFFICE USE: APPLICATION FOR"SANITATION PERMIT (Complete in Triplicate) Permit No. 3-C?......... .�• ,. _____ ________________ This Permit Expires 1 Year From Date Issued Date IssuedQ_=1a.9 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/LOCATION _---------------------------- ----- ------- - CENSUS TRACT -------------------------- ---- - -- - - Owner's Name ----�'2�--- -------_ --Phone -------------------------- ----•---- Address --------------•------ C City -- -------- ----- Contractor's Name . __ _ _ - __ -� __.ticense # _ l/r7-'-'>- Phoney ' -3_/_V_&— Installation will serve: !/ ResidenceVApartment House[] Commercial❑Trailer Court ',❑ s Motel ❑ Other -------------------------------------------- Number of living units:.__----- Number of bedrooms -___Garbage Grinder __________ Lot Size -_ - --rl_-5-__v_�_____ J --- Water Supply: Public System and name f.CL -------------------------------------------------- -----------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ .Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .[:] Hardpan ❑ .Adobe;g[ Fill Material ------------ If yes,type ---------------------------- .(Plot _______________.__-_-___.(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) ooh NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ,^} Size PACKAGE TREATMENT { ] SEPTIC TANK' __! _/� S� !, i X Liquid Depth X- 4 Capacity V ------ Type ~ Materia l_l��'___C_�---- No. Compartments Distance to nearest: Well -- �'' 't-P -----------Foundation __, ---------.- Prop. Line ----45- i / r LEACHING LINE 1W_ No. of Lines Length of each line___ --------------- Total Length -----�!9--------------- 'D' Box --------I---- Type Filter Material S�/<__0 "'.Depth Filter Material -------- ---------------- Distance to nearest: W.ell�--___- Foundation --------------- Property Line -___-��__--_____._.___ SEEPAGE PITDepth, c =s __.__ Diameter _________ Number ______________ Rock Filled Yes yj No Water Table Depth ------(L%- ---------------------------------Rock Size -0 --X-?---'e-1-- Distance to nearest: Well ----------- -Foundation -------- Prop. Line ---• ..--.--•--_-- REPAIR/ADDITION(Prev. Sanitation Permit# ------------- ------------------------------ Date ----------------------------------- Septic Tank (Specify Requirements) ________________ I II It DisposalField (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, 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 perform 'ce of the, ork for which this permit is issued, I shall not employ any person in such manner as to beco e u Wor man's C nsati.on laws of California." Signed - Owner BY ------- ---------------- - - - -- - .-•��___J��= Title ---------------- (If other than ow I " FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --- ------------------------------L� ----------------------------------------- -----. DATE G ------------------ - BUILDING PERMIT ISSUED ------------I---------------:-------i -------------------------------------------------- --------- -----------DATE .------------------- ------------- --- AQDITIONAL COMMENTS ----------_ i __ _ - - I. -----------------------------------------------•-----_ _ ; -------------- - ----- ----- ------------ , ; L ------------- ---------------------- - GA �Final Inspection by: Date i SAN JOAQUIN LOCAL HEALTH DI5 k ;�f-'H. 9 1,-'68 Rev.,5M