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FOR OFF E USE: �� APPLICAT(ON F6R SANITATION PERMIT �f/ (Complete in Triplicate) Permit No. //`/"4 ------ ------- �j ------------------------ This Permit Expires 1 Year From Date Issued Date 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATIO ' G�F D S ..----CENSUS TRACT ---------------- Owner's Name ------ -- r. �- �.- ------- -------- ----------- -----�----- - -- hone Address -- . 1 Cly--� - ------- + L ---------------- City _ Contractor's Name - ------ - .-------___"-- ------- ----- -----------.License Phone K67.X?;F 1O_1? Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court Motel ❑Other ---------------"""--- ---------------------- Number of living units:-----/ Number of bedroo s ___Garbage Grinder ------------ Lot Size _� :5^.1�3�4 --- ------------------------ ___ - Water Supply: Public System and name ------------- _T, -—-------{ii-f�--�--------------------------------------------- Private E]Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay El Peat❑ Sandy Loom [] Clay Loam ❑ Hardpan ❑ Adobe X 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,) ,r PACKAGE TREATMENT [ ] SEPTIC TANK: Size _ .�_ �''" ---_.- Liquid Depth __ .-.""_ � Capacity�r Q_ta. ,1Type _ rht Material No. Compartments .2— 00 Distance to nearest: Well __--_ -------------------•Foundation --- -------- Prop. Line ------ / ------ __-- -- _ " LEACHING LINE )<L-- No. of Lines --- ----------------- Leng th of each line-----------�,�`.""---_ Total Length 47-0_"-"-- D' Box ____ _____ Type Filter Materia! -J----- _� ----- "pepth Filter Material _. _ ;n ----•-•--- V Distance to nearest: Well ---��----------- Foundation ____ --------- Property Line ---- ___ --------- SEEPAGE _______SEEPAGE PIT Depthr-_--- Diameter _ ' r Number -------Z'_______________ Rock Filled Yes E�' No ❑ Water Table Depth _________ dr ----Rock Size -----o:Z-- ------------- Distance to nearest: Well ___"_ �" -------------- --Foundation ---zlea__ Prop. Line ------- REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- Date Septic Tank (Specify Requirements)•-------------------.____._ - ------------------------------------------ Disposal Field (Specify Requirements) F ------------------------------ ---------------- -------- --------------------------- (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 Sass 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 performance of the work for which this permit is issued, I shall not employ any person in such manner as to become ct t orkman s Compensation laws of California." Signed __-__ e,.�.t�_ _ ---- - ----------- � --- ------ ----------- --- Owner By ---- -- ------ -- - --- --------- Title ------- - ------ --------------------------- ot er than owner FO PARTMENT USE O LY APPLICATION ACCEPTED BY ---- ---___ ------ "__ DDATE BUILDING PERMIT ISSUED -f F ADDITIONAL COMMENTS DATE ---------------------------- ---------------------- ✓ �f11 ----------------------------------------------------------------------------- -------------------------------------- ------------------------------------ - ------ ------------------------------------ - ---- ---------------------------------------------------------------------------- Final Inspection by: __ ____ _ _ ------ - --- --- - - - - -- - - - - - --------- •- - - - -- -- - ------------- -.Date --- ._ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M