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FOR OFFICE USE: APPLICATIOWAOR SANITATION PERMIT i (Complete in Triplicate) Permit No: -- -------------- ---------=--------------------------- ------------------- --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued _6_._7Z--- Application is hereby made to the San Joaquin Local Health-District"for`-'a„-permit`"to conitruct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing-Rules and Regulations. JOB ADDRESS/LOCATION ......�--�-------tZ�o �/V e=_!-�1�-—-----------------------------CENSUS TRACT .� L _----------�-----. ------ JOwner's Name - - -------C ----Phone ----------------------------------- --- J`-City � b ' -------------------------------- Address Contractor's Name _____ _________ _ �License#/6._j.�_.?_,� hone __56_--_____--------�-� Installation will serve: Residence ' Vartment House-E] Commercial :❑Trailer Court ',❑ Motel ❑Other ---- tom^ J Number of living units:.___ :____ Number bedroorris �_____Garbage Grinder !.(C`:3_____ Lot Size i� �!� _ ___________ Water Supply: Public System and nam / ❑ ----- Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay 0 Peat❑ Sandy Loam [] ' Clay Loam;❑ 'kHardpa 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,) PACKAGE TREATMENTSEPTIC TANK f2 [ � Size------' _--w- - ------- --- ---- Liquid Depth -----------------•-------- Capacity Typ = _'/- b_3 r'�_-Material__��Jr-r4No. Compartments ---------------------- Distance ___------ _____-:•-_-Distance to nearest: Well --------- -___________-----Foundation ----/?q__1 Prop. Line s------------_______ LEACHING LINE [A.].-'No. of Lines Length of each line_ 'S' ' ----- Total' Length .............. 'D' Box e-,)--- Type Filter Material 4-64--____Depth Filter Material __ f a ej Distance to nearest: Well --------- ------------?•Foundation __________._______ Property Line _.5-__----.-__._.... SEEPAGE PIT Diameter Number _______. ------------ Rock Filled Yes 'K]_ o I❑ J� 3 Water Table Depth --------�-�-----------------=--------------Rock Size -- --��-x--�--------.:--- -� --- Foundation Prop. Line .....J..... ........ n. Distance to nearest: Well _________________ REPAIR/ADDITION{Prey. Sanitation Permit# --------------------------------------------------------- Date ______________.__________________-) SepticTank (Specify Requirements) ------------------------------------ ------------- -------------------------------------------------•----• .--------------------------- f Disposal Field (Specify -Requirements)- ------- [ -------------------------------- !----------- ------------------------ ---------------------------------------------------- ------------------------------- --------------------•------------ -------------------------------- ------------------------------------- --------------------------I--------------------------------------------------------------------------------------------- (Draw existing and required addition on reverse side) 1 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: 6 "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 twbecome subject to Workman's Compensation laws of California." Signed ----------------------- '.- ----------- Owner - y BY " - TitleG �-------------------------------- --------- (If other than own � . i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYC•__6.___ �" j -- - ------------------------- - -- -- ----------------- DATE �--------------------------------------- BUILDING PERMIT ISSUED ---------------- -- ------- --------------------------------------------------------------DATE ------------------------------------------- ' ADDITIONAL COMMENTS -- ---- ----------;--------------- __... ------------ --- - - ------------------------------------------------------------------------------- ------------------- ----------- ----- ------- ----------------- --------------------------------------- --- -------------------------------------------------------------- ------------------------------------- ----------- ---------- -- - • '� --- --- ------------------------ - - Final Inspection by: i J ---- •---------------------------------------Date --------- --�'---- _ i SAN J, AQUIN LOCAL HEALTH DISTRICT , E. H. 9 1-'68 Rev. 5M ' e � -