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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Permit No, -- -------------- ----------- -------------------------- (Complete in Triplicate) ------------ ----- . . This Permit Expires 1 Year From Date Issued 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 .__f�. '.zr_ ------- h l t_f may- ---------------- ------------CENSUS TRACT Owner's Name ----._ - Phone ------------------------------------ - f -------------------------------------------------------------------------- City ___S-/-1 -------------------- ----------------------------------- X ---------------------------------•- . Address _---- ��'-''�---- -' License # _l77_ -3__ Phone Contractor's Name ./ _S__- __LS ��- ---------+ - -------------- Installation will serve: residence Apartment House❑ Commercial ❑Trailer Court l❑ Motel ❑Other --------------------------------------- -- Number of living units:____ ----- Number of bedrooms __A/----- Grinder _mil-._ 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;K Fill Material ------------ If yes, type ---------------------------- (Plot pian, 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 TREATMENT [ SEPTIC TANK'[ f Size_- --- - 1 '-X-- ------------ Liquid Depth _5--------------.----- l� L f Material4/Ul�� No. Compartments - --------------- \J Capacity A�G - Type Distance to nearest: Well _5�e--------------------------Foundation ------ Prop. Line _f'_-___:_.------ s LEACHING LINE [ No. of Lines ----o --------------- Length of each line......... -------- Total Length __/_�- -r-.---------- 'D' Box _/L=_S. Type Filter Material .�C�_CIC--_-_pep#h Filter Material -_-] -------------------------- ----- a Distance to nearest: Well ----3-f?-------------- Foundation __L-19 ------------ Property Line. __s----------------- �7-�z-��- Number .------- --------------- Rock Filled Yes � No : ' SEEPAGE PIT [� Depth -_______-- Diameter `/ �� r, Water Table Depth .k,3-t Rock Size ----- J�XW--- to nearest: Well ---/4_V--------------------------Foundation - /_ --------- Prop. Line ___ ..�..----....-- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ ------- Date ----------------------------------) Septic Tank (Specify Requirements) -------------------- ------------------------- ----- - ------------ i Disposal Field (Specify Requirements) ------------ ----- ---------------------------------------------- - ----------------------------------------------------------- - - - -------- ---- -- - - - - - ----------- -------- - ------------------- --------------- - {Draw existing and required addition on reverse s d e 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: a "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 becomes bjec t Workman's Compensation laws of California." -- ------------------------------------------- Owner Signed By --------- Title -------------------- --------- ----------------------------------------- - - (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -_- --------------------------------------------------- -------------- DATE ----- -1- ------ ---------------- -- ------------------------- APPLICATION PERMIT ISSUED ------- DAT -- - - ------------------------------------------ ADDITIONAL COMMENTS - ------------------------- ---- --- ------ ---------------- ----------------- ------- --- ---------------------------------------------------------- ------------------------------------------- - - - ----------------------------------- --- -- ---- -------Date __ - -------------------- Final Inspection b -------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H.-9 1-'68 Rev. 5M.