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FOR OFFICE USE: rti 3� APPLICATION FOR SANITATION PERMIT ,.....................1111-.................l. ...... (Complete in Triplicate) Permit No. 1111...-1111.. ............................... ......•---- T. .- This Permit Expires y Year from Date Issued Date Issued ..G.�,........, 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 Count Ordinance No. 549 and existing Rules and Regulations: JOB ADQRE55/LOCATI .......... ....f ...... ...................................CENSUS TRACT ......... Owner's Name ... L�.........._X_'X. .�. a. --Phone ............... Address ... •" ... --..-1111.- ....fi...-1111 City �,................ ... F � Contractor's Name -,_ ---_-_-- _ �.�, .. Y _.�+-c.e,.t License # iC'. ' 1.��.. Phone Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 Motel E]Other ----•------- .............-1111.............. Number of living units:-..:- - Number of bear oms -_►2.....Garbage Grinde 'Lot Size Water Supply: Public System and name .---.-.. -.. �,1 ----••---__--...--•---------------111 ..............Private ❑ � ��1 ..... Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peut❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe 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.] NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} 4 �� r! Fi PACKAGE TREATMENT [ a SEPTIC TANK� ],�`i�' ��............................................. Liquid Depth .............................-----_-•--111:1.--.........._S Capacity ----------- -•-- Type ... Materia(.................1111. Na. Compartments ...:............ Distance to ewell .............. ..•__-_-____•-_-_-_Foundation .......................,Prop. Line ......................t_ j + ��drre .. o ....--....--- Tota( Length -••.........................mnLEACHING LINE s _-- Length of each line............ I 'D' Box ------------ Type Filter Material .Depth Filter Material •--- -1111----•--...---- ...........1 .............................. Distance to nearest: Well ,-_-1------------------- Foundation ......................... Property Line ................ f SEEPAGE PIT Depth Diameter IV-"... Number .....-c-2................ Rock Filled YesV No Water Table De` th_...... .. ` _. --- ..-.... ...r .. Rock Size P �-•---•--- ---- ----------------11.11... Distance to nearest: Well .. . .........Foundation ........... Prop. Line ............. 3 REPAIR/ADDITION(Prev. Sanitation Permit 4 -•.:------------.--------..............: Date ___............................... J ► Septic Tank (Specify Requirements} ................... .. .... ....................................... ........w. -1 .}1111-...- Disposal ield {Specify Requirements) r.... .......,7 _111._.1_ .............. �„_----- �. ..-... ----._ .....................••----....-- ....-..-- -- tR 1111..�.-.. -- _ .- .-.. -al� ►�-.. -1 .----._- :� ......................... ....._.___.-__...-----.-._..-.............................. IQraw axis ' g and requ' ed 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, Horne 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 any person in such manner as to become subject to Workman's Compensation laws of California." Signed---------- ---. ......x.......................... 1s1...11,... 1.111--.. Owner � . eTitle ........................ BY ------ - - I Ilf other than owner} APPLICATION FOR DEPARTMENT USE ONLY ACCEPTED 8Y 1111. 1111. ,... ,..1.1.. DATE _1111 " _.0`- 1111... BUILDING PERMIT ISSUED .............................. ...... ..... ....... ........DATE ................I.................... .. ADDITIONAL COMMENTS :............ .....•------------------•------•----........:•...........................................:......................................... ........... .................... ...... •-- ......_. ._....--- .Date .. :.�.f .._- ...:--.... . ........... . . -- - -- _:. . 1111_ .-.. I Final Inspection by: __... :... .. ,/ SAN JOAQUIN LOCAL HEALTH DISTRICT y� E. H.13 24 1-'68 Rev. 5M - -- 7172 3 M