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1 FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT/ '� ----------------------- -a_ (Complete in Triplicate) Permit No .�- T .!----- -J�d-------""------ l _- ---/ Date Issued ---- ---"- ,* - ----------------------------- This Permit Expires 1 Year From 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/LOCATION -- - - ------- ------------ CENSUS TRACT Owner's Name { ~ e ,1-�? -- ------------ - Phone Address �. - // City ✓C' !sem Contractor's ldame =� ��"� -----------------License Installation will serve: Residence artment House,❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ------------------------------------------- Number of living units:------- Number of b oo n __- arbage Grinder _ - - Lot Size _ __ -- ------------ Water Supply: Public System and name __-- _ -•- -- ----�--.�---� ----- ------- ----- ----•----------------•------•-------•Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam:❑ Hardpan ❑ Adobe,flV Fill MateriaJ410-_--- If yes,type ---------------- ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) r NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet, LV PACKAGE TREATMENT [ I SEPTIC TANK f ] Size---------------------------------- - ';! Liquid Depth ------------------- Capacity ---- Type -------------------- Material---------------------- No. Compartments ------•- --------, p Y ------------ - Yp ' Distance to nearest: Well ----------------I-----------------Foundation -1--------------------- Prop. Line ------- -------------- LEACHING LINE [ ] No. of Lines ---------------- ------- Length of each line------------------------------:---- Total Length ------------------ 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------.------------------ -- - . Distance to+:nearest: Well"""'-------------- Foundation ------------ - Property Line ---------------------- SEEPAGE PIT [ ] Depth -------------------- Diameter --_-_----------- Number --------- r- ---------..Rock Filled Yes ❑ No i❑ Water Table Depth ------------------------- " _ -=----==`=----�:RockLSize = ` i Distance to nearest: Well ------------------ -------------------'--------•---------Foundation "-- -- _------- Prop. Line --:'--••------------- REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- -------------- Date --`---_---- -:-----------------] Septic Tank (Specify Requirements) --------------------------------- --------------------------------7------------------^----- ---.--------- ---------------- D's sial Field {Specify requirements} --------� - ---- :. � . aw 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 Health District. biome 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 Compens tion laws of California." Signed ------------------------- -- -------------- Owner ---------------- - ------ Title - /` �'- ------------------------------ (If other n owner) FOR DEPARTMENT USE ONLY APPLICATION AC TED BY -------- --- -----. DATE ----C�_�l `----- ---------------- - ------ ---------------------------------------------------------- BUILDING PERMIT ISSUED -- .-'---------------- --- - DATE _.--------_- `� l L- ADDITIONAL COMMENTS -e�z" � '" -------- ------=�--------------------- ---------------------------------- -=---- -- ----- ----------- ------------------------------ --- ------------------------------------- -- ------------------------------------- - -- Final Inspection by: Date __"-- --``_ � -(• SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M.