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FOR OFFICE USE: APPLICkFIOf FOR SANITATION PERMIT �ff �e� (Complete in Triplicate) Permit No_ ______________________ This Permit Expires I Year From Date Issued Date Issued -----------6� , 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 ma a in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADIJRESS LOCATION ._ ----- -- --- -�---- ---------=------_ �� CEN U / D7�� / Owner's Name -------------- -, - - --------------------------------------------------Phone,/ ---- ------ ----------- - --------------- ------- - Address ------ ---- ------------------- ! /A! ------- city Contractor's Name ---------------- ---- -- --- --------.License # ---_ -I�-:--------___--- Phone _ Installation will serve. ResidenceApartment House❑ Commercial ❑Trailer`Court ',❑ ; Motel ❑Other ---- ----------------------------- ---------- Number -------- ----------------- -Number of living units:-----/-.--- Number of bedrooms ----3-___Garbage Grinder A0---)I Lot Size -------- Water Supply: Public System and name ---------------------------------------------------------------------------- Il---------------------------------Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy E] ,�Clay Loam❑ Hardpan ❑ Adobe` Fill Material If ye, type --111... ,i (Plot plan,=showing size of lot, location of system win-relation•to,welIs,-buildings;-etc. must be placed on. reverse side.) # 01 f NEW INSTALLATION: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,)' PACKAGE_TRI:ATMENT)� SEPTIC TANK'[ ize______ _ L uidDe Dept __ [ ,------ --------------------- -q P apa�city��._ __ __ Type __ ___ _ _:r°°�_ Material(�?� No. Compartments (� f --- ------- .Distance to nearest: Well ----�`� 7F-----------------Foundation ?_,IlQ___. '�^Prop. Line ___------------------- LEACHING Q -- ----------- LEACHING LINE �1 'No. of Lines _____-__._._____ Length of,,,each//line--------?s�__.'�`-_-___ Total Length __I�O______________ i t .,f _-De th Filter r 1 Y • - p' /f D' Box ______._"'-T pe'Filter Material p Material .....�.�_______.______ _ _ _ _________ �D.istcince toiriearest:.Well-46Q.____--�_'_ Foundation -r__ _______ Property Line __._ 5�-.-3r- Number ------- .-- - SEEPAGE PIT o ` De th __ .. ____ _ } j /M.-____-- Rock�Filled Yes No I❑ [ ] p Diameter ii I i/ Water Table Depth ------A--------------------------------------Rock Size -i,5'- �Z/----- Distance --- �.____ [Prop. Eine _._.. _------------ n __ �{� Di stance to nearest: Well ------�_�________________________Foundation __._�_ ____.__._ !. '` ! I REPAIR/ADDITION`(Prev. Sanitation Permit# --_-.�-��_.�_______________ Date _,!��L?�+�_ 7__-____-__} uir�rnerits} -=_- f-------------------- ----- - ---- --------------------- Septic Tank{Specify-Re ' Disposa! Field (Specif Requirements) 1-111, ------------------------------- --------------- --------------------- A---- h r ,� -------------- --------- -- ------------------- ----- ---------------------- ------------------------------------------------------------------------------------------------------------------ -= - ...-- �. y j {Draw existing and required-addition on reverse side y-certify that°I•have re ared-"this`a--litatioe`and�-that' the work will�be don---------------------------------------------------------- I hereb fy p p pp a in accords a with San Joaquin County Ordinances, State laws, and Rules and Regulptions of the San.Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: 1 II "I certify that in the performance of the work,foie which thisr-perme5 is issued,.hall not employ any person in such manner as to become subject to Workman's Compensation laws oCalifornia�" 4 �� Signed ------- ---------- ------------ --- Owner ?� BY - r r ------------- Title ----------- _-~--- �. -------- - ----- - - - ---------------- - - - ---- - ---------------------------------------- (If other n owned FOR DEPARTMENT USE ONLY - - APPLICATION ACCEPTED BUILDING PERMIT ISSUED ---------------------------- - --------------------4------DATE -------------------- 1 ADDITIONAL COMMENTS -------------------------- - it �I _ r ' ----------------�-----------------�i ----------------------------------------------------- ----�i--------- -�--Y------------------------- -------------- - Final Inspection i� - - P Y f, • Q- - - - - -- - = 7 3 ` _ - -----Date _._. ... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M