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FOR OFFICE USE: �-ry APPLICATION FOR SANITATION PERMIT .....__..^....................... >1` I - Permit No. ...7. .::'.`1 O� (Complete in Triplicate) :_._..... ' ......................... 3 _ J --Dat6]1!sued�.:.........—. ... ----------------------------- This Permit Expires 1 Year From Dane Issued _.. . r , ( 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: �� /.. '/..V'f2G.. ,1"�CENSUS TRACT ...... ......... JOB ADDRESS/LOCATION . .-___. - ... .... _ . y Owners Name , --k!.1...�^ '. .....................$ Phone ....................... S ...Address _-.. �, . ....-.....� .. City .................................... ..... Contractor's Name _._-. ..�/ -.License #oi rl:sr�?.._ Phone s ... ... F Installation will serve: Residence ZApartment House❑;Commercial ❑Traller Court t Motel C]Otlier ' I n ., /. _.. . ..=.. ------------------- Number --------- ---.---.--- um er of living units: _ �... . Number of bedrooms _4�_.. Garbage Grinder- - ------L--o-t-•-Size Water Supply: Public-System and. ame -•-••----•-••-----., / Private ❑ r Character of soil to a depth of 3 feet: Sand j] Silt❑ Clay ❑ Peat❑ Sandy Loam p Clay Loam "Hardpan ❑ Adobe Fill Material __... ...... If yes,type ............................ �l {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.feetJ " k PACKAGE TREATMENT [ SEPTIC TANK ] Size.................................... --------- Liquid Depth ................ Capacity ..._... Material..........:.... . No. Compartments -------•---•----.... Type ------------- ' I Distance to nearest: Well ....................................Foundation....................... Prop. Line ...................... LEACHING LINE [ � No. of Lines ................6------- Length of each line---------------- `.-..__-..: Total Length ............................ D' Box ------------ Type Filter Material '..:.................Depth FilterMaterial--- ___.......__....._._.•......•...... Distance to nearest: Well ........................ Foundation _..._............._____. .Property Line ........................ SEEPAGE PIT � `t Rock Filled - Yes�'.- No Q [ ) F' Depth ---------------•---- Diameter �-•--..........._ Number .---------•-•--;:. = '� Water Table Depth ---_-.-..Rock Size ti. Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit # ............................................ Date ........... ............._.......} Septic Tank (Specify Requirements( y ........_........ . ..... .. .!. .` --' `6•.�. .Gam--?-- ----�--°1--- ------------ .-- - -- Disposal Field (Specify Requirements) -� -.._... ....................... .......... ..........................---•------•--------------------• ...•---........> --•-••- ----------------------------------------------------------- M(Draw existing and required addition on reverse side) I hereby certify that 1 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 l€cen. sed agents signature certifies the following: "I certify that in the performance of the work for which this_permit-,is;iissued,_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 o than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .......... ..... . .. . . ...................r..........................:.................... DATE .---..------. BUILDINGPERMIT ISSUED ----------------- ...........................................'------------------------.._... ..............DATE ....................... ................ ADDITIONAL COMMENTS .................:...........'-- ....................................................... ....................... --------- ............• ................................................._..._........._........_._.. --•---------------. _ .. - FinalInspection-by: ...:...: ..... ........... ........................................................................... ate .....J.... ............. . ............ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.3•-3 24 1-'68 Rev. 5M `' 7/723 ,14 i