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F FOR OFFICE USE: 16� APPLICATrON' FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------------- ------------------------- ----------------------------------- --------------- This Permit Expires 1 Year From bate Issued Date Issued '"73 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: i E � iiff JOB ADDRESS/LOCATION ----JI`:ry_ -------- /Sx� / _. ------'4/ ,-----------------------CENSUS TRACT ---- --------,----------- Owner's Name ----- :--------=Z -------------- _------------------- -Phone Addeess ---------SAXI� --------------------------=---------------------------------------------------------------------- Cit ". -_ T Y ST ----------------------• ------- Contractor's Name License "_ Phone Installation will serve- Residence ❑ Apartment House,Q Commercial:❑Trailer Court ;❑ ! , Motel ❑ Other -------------------------------------------- Number of living units:__. _____--_ Number of bedrooms !1 r _�------Garbage Grinder ��."-- Lot Size _-I�-----�'-1�4.---------"_""-- Water Supply: Public System and name ________________ ------------------------------------------------Private ❑. Character of soil to ardepth of 3 feet Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ _ Hardpan ❑ Adobe 2t Fill Material ------------ If yes, type ---------------------------- (Plot _-- --__-_----------------(Plot plan, showing size of-,lot, 'Iodation of system in.,.relation' to wells, buildings, etc. must be pla eclon reverse "side.] NEW INSTALLATION: (No septic:tank or seepage pit permitted if public sewer1s Available within 200 feet,) PACKAGE TREATMENT - Liquid .Depth -----------•----,----__ [ ] SEPTIC TANK�[ ] Size------------------"_-_----------- --- -- -------- ----------- I '•-.Capacity --------------------` Type -------------------- Material-------------------------------- No. Compartments P ---------------------- ` kDistance to Barest: Well -------------- ----------- -----Foundation-,-------------------- Prop. Line ---------- :------_" ------ LEACHING LINE, [ ] No. of Lines --------------------------_Len6th..of-e'ach-line otal` Length ----------- -----------•---- S- 'D' Box --- ----- -- Type Filter Material --------------------Depth Filter Materlal_ --,---------------------------------- - - -Distance to nearest: Well ------ -Foundation --� __________ _ __ `Pfoperfy—Line t SEEPAGE PIT [ j Depth -------------------- Diameter --------- `Number 1----------------" Rock Filled Yes ❑ No :0 Water Table Depth ---------------------------------------=--------Rock Size Distance to nearest: Well _____________________ -----------------Foundation -------------------- Prop. Line --• ------ ' REPAIR/ADIDITION(Prev. Sanitation Permit# --------------------------------------- __ Date Septic Tank (Specify Requirements) -------------------------------------------------------------------------------------------------------------- •---------- ' Disposal Field (Specify Requirements) _________ 4 --------------------------------------- { ------------------•---- ° ------------ ------------------------------------- ----- ------- -- - - - ------------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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 stealth District. Home 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 ----------- Owner BY ---- ---------- ------ Title - (If other than owner j FOR DEPARTMENT USE ONLY !� APPLICATION ACCEPTED BY __ lt. ------------------------ -------- DATE ----` � ~ BUILDING PERMIT ISSUED --------------`------------------------- ------------DATE ADDITIONAL COMMENTS --- ---------- ; ------------------------------------------------------------------- - ----- --- -- ----------------------------- -------------- Final Inspection b Date j P Y= ---- --------- ------ - - ------------ ---- - -------- --.------ - . -- -- ---.------------ SAN JOAQUIN L CAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.