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FOR OFFICE USE: d . .� APPLICATION FOR SANITATION PERMIT ,/ - ,* �- " SYS ' (Complete in Triplicate) Perm,rit"No, __ _ . _____. - --------------------------------------------------------- This Permit Expires.1 Year From Date Issued Date Issued _00P Z_�_.. 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 . — ----`---- ---------- ------------------CENSUS TRACT ---------------------_-- E. Owner's Name --p---:---�'- �2 _ `~ S e_ - -�rl-s-k-¢ n-------- ---------- Phone n - -- -----------. city --- f --El� ------ -----------------------------••-- Cotractor's Name ` ��. ------.License # Phone Installation will serve: Residence i,N Apartment House^❑ Commercial ❑Trailer Court i❑ Motel ❑ Other--------------------------------------------- Number of living units.,--I------- Number of bedrooms ---- -_-Garbage Grinder ---IZ-[2- Lot Size .___ ---------- Water Supply: Public System and name --------- -- -----_-- r -r_e-f------------------------.---------------------------------Private ❑ I` Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe K 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 side.) Ilk NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' ' t PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size---------------------------------------- ______ Liquid Depth -------------------- i Capacity --------'--------:Type ____________________ Material---------------------- No. Compartments I Distance to nearest: Well -----------------------------------Foundation ---------------------- Prop. Line ------- LEACHING �-� LEACHING LINE No. of Lines ________ __------------ Length of each line______ _ __.- ------ Total Length -------_---- V _.---._.._'D' Box ___O... Type Filter Material ______ _______Depth Filter Material ----------k 9-__•----------------------- Distance to nearest: Well -----l- r Foundation ---- ............ Property Line, ...r.Vll.......... SEEPAGE PIT ( ] Depth _____________'______ Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No ❑ ,l 9 Water Table Depth ------------------------------------------------Rock Size ----------------- -------------- Distance to nearest: Well -------------:__________________________Foundation -------------------- Prop. Line ...................... R PAIR ADDITION(Prev. Sanitation Permit#.-------------------------------- Date ____________________----__--______} I Septic Tank (Specify Requirements) ------------------- -----------------------------------------------------------------------•---------------- - // f i ( Disposal Field (Specify Requirements) --------------/k, 0- • ... eco- h----- 'a n e- ------------------------------- 0 -- --------� '�----------F /1-------- } --------------------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------ (Draw existing and required addition on reverse side) i I hereby certify that I have prepared this application and that the worts will be done in accordance with San Joaquin I 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 "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 Workman's Compensation laws of California." ' Signed ------- - ----------------------- ner Tit e F? BY -------------- ------------- -------------------------------------- --- (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = - ---------------------------------------------------------------- --------------. DATE ---- ------------------ BUILDING PERMIT ISSUED --- ------------------------------------------------------------------------------=--------------DATE ----------------------- ' ADDITIONAL COMMENTS ------------------------------------••------------------------------- ------------------------------ ---------------------- ----------- --------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- -------- ------------------------------------ ` Final Inspection by: ______ _ Date -------------------- t G SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M