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,F6R OFFICE USI`: APPLICATIONXOR SANITATION PERMIT . .s _..........._` s� Per .. No. :� t (Complete its Triplicate) _ ,. .,.,._ ..._.__.. �.... .......... ......I............... _..-- --- " 4xr _ 3#- ,,� ,� � -��- ©ate Issued�-.�•-`... ............ .• This Permit Expires 1 Year From Dow Issued 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. 50 and existing Rules and Regulations: .........CENSUS TRACT ......... . JOB ADDRESS/LOCATION ..... '._, ... .•-! 11 ......... Owner's Name ....._ ... { ....Phone ••---....... .,. ............................... Address .. .. ..,.. ..... ... ...E,'^-r. .. ...................................... ..................................... _ City : : ... Contractor's Name _.... i( f �►.... License ..jam. Phone ................... ..... Installation will serve: Residence ❑Apartment Houseo Commercial ❑Trailer Court ] Motel ❑Other ..--------- .............................. L 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❑ Sandyy loam ❑ 4? Hardpan Adobe 0 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 s1de.1 NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size..... ------ ••- ...l??•.... Liquid Depth .. '. ......... .P Capacity -- - - e "------------------ Material----.---....------.... No. Compartments �.. Distance. to nearest: Well ...-- � ��• -------------Foundation ... C?............ Pro ••....... LEACHING LINE [ ] No. of Lines -------/........... -• Length of each line.----- ........... Total L gth ....... .... 'D' Box ...... Type Filter Material ....................Depth .Filter Material ......... Distance'to`nearest: Well __---- ----------------- Foundation ..... ......... Property Line ........................ ,}I SEEPAGE PIT [ j Depth �.�-�-- /�Diameter ................ Number ........... ............ Rock Filled Yes No C WaterTable Depth ---------------------------------------------•-..Rock Size ................................ -_....Foundation .......... ...... Prop. Line ...................... REPAIR/ADDITION(Prev Distance Sanitation Permit*Well : :-------- _ Date ._._...._...------ . ---------••--) Septic Tank (Specify Requirements) -----------------------------------•- ......................__...__..�_._+ ....... .......................................................... Disposal Field (Specify Requirements) ------------ ..---'------.--=-_...--`--.............................:.....-•-.....,.. . -------------------------------= ------ -------------- -------"----- -----------------------......_..----.............................. _..•-. -------------------------------------------------------------•----•------------•---------- ............-------------..----------------------------------------......................-........... ..... k (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 liven- 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 mannan as to become subject to Workman's Compensation laws of California." Signed --------"- n ---� -•- ----•-•- --; ------------------ - ......... Owner By ............... -- � -------- Jitle -------•--• -- ------------- . ..----......------. owner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .... --- Y_ . ---• ---:-- ---- ---- :. =------- ---. DATE ...✓. _/G7 �. BUILDING PERMIT-ISSUED ". ...... .......... _.DATE ------------------------ ._..... DD O COMM-E A --- - -;- -----• ..... ` .. -- ------ b t9. o � ------------ -- -------- Final Inspection by: .-- .. ....................Date ... •.............. Ell 13 .2h 1-58 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M