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FOR OFFICE USE: KSan PPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No:7.4.___5S--_____. ------------ ---------------------------------- _-_-________-- This Permit Expires 1 Year From Date Issued Date Issued Application is hereby made to thaquin Local Health District for a permit to construct and install the work herein described. This application is mampliance with County Ordinance No. 549 and existing Rules and Regulations: i\ E JOB ADDRESS/LOCATION ._ _�� " + T_ __ CENSUS TRACT :____-_ Owner's Name �� /-- ° e � " 4 Phone- = �/- Address ----------------------------- ---------- = _. City -- - V Contractor's Name ------ _4----- --t License #f t0 - Phone _.W -f' _e Installation will serve: Residence %Apartment House[] Commercial ❑Trailer Court ❑ / Motel ❑ Other Number of living units:--------1 Number of bedrooms ____�'Garba_ge Grinder -----------" of Size --------- 6_>C13 Water Supply: Public System and name --------------- ---------------Private [] Character of soil to a depth of 3 feet: € Sand'❑ Silt❑ Clay ❑ • Peat❑ . Sandy Loam ,E] Clay Loam ❑ Hardpan ❑ Adobe)( Fill Material ------------ If yes, type ____________________ (Plot plan, showing size of lot, location of system inrelation'to wells,"buildings, etc. must be placed on reverse side.) NEW INSTALLATION: (No septicltank or seepage pit permitted ifpvblic sewer is available within 200 feet,) I 1,_ PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] .4 w Size_________________________________"___-__------ Liquid Depth _______________ % Capacity ' -Type-=-+---------------- Material---------=----------- No. Compartments -------- --- Distance to nearest: Well __=______------------------____-Foundation -------------------- Prop. Line ____________. ---__ LEACHING LINE [ ] No. of Lines ___- f -�--�_-�_-- __ Length of each iline---------------_1- i ---------- Total length ------------•---- 'D' Box .--___-____ Type Filter Material ____________________Depth ,Filter Material ___----______ ---------------- Distance to nearest: Well ________________________ Foundation ------------------------ Property Line SEEPAGE PIT [ ] Depth ----- --____t Diameter ________________ Number -__---_--____^_:___'______ Rock Filled Yes L] No 0 t ». rr r_. r Water Table Depth ------------------------------------------------Rock Size ------------------------------- I Distance t nearest: Well ----------------------------------------Foundati., n --------------------- Prop. Line --__-____-____---_ REPAIR/ADDITION(Prev. Sanitation Permit#--------------------------------------------- Date -------------------------------•--1 Septic Tank (Specify Requirements) ------- --------------------------------- ---- - . I - Disposal Field (Specify Requirements) 7" �04_ '--- ------__-7_-!'-----1�_ ------------: ------ ----------- ---------------------------------------------' (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 San 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 _ I as to become subject to Workman's Compensation laws of California." Signed ------ f -- ------ ---- - --- ---- ---- _� Owner � BY / ------------------------------------------------------ Title ----- ------------------ other t owner) -_ FO EPARTMENT USE ONLY APPLICATION ACCEPTED-BY•'�'-__ , 7 - - ------------- ---- ------ DATE' / ------•---- BUILDING PERMIT ISSUED _�__-__-_ _ _ - y ADDITIONAL COMMENT --- -- - ---- - �? ' ----- --------- ---- -------------------- -- /r f � ---� -4r �- ----- s ------------ ------- t { *x ms --- ��T 7 e-r ---------------------------------------------- Final p_'tion by. -------------Date ------5-� ------------------ `^� 1� A AQ IN LOCAL HEALTH DISTRICT t E. H. 9 i-'68 Rev. 5M _ .�