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FOR OFFJCE USE: .. _ APPLICATION-FOR SANITATION PERMIT ------------------------------- ' (Complete in Triplicate) Permit No: --------------------------- ----------------------------------------- ------- 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/LOCAT N _ - ------ --- ---------------------------------CENSUS TRACT ------------------ Owner's Name ----- - _--------- , Phone ------------- --------- Address --------- ------• -. City f�� 1 �o I Contractor's Name 'l -----------------------------------------License #� i Phone Installation will serve: y}�'tkesidence Apartment House❑ Commercial : Trailer Court . 'v a � Motel 0 Other -------------------------------------------- Number of living units:--___ ___ Number of bedrooms --fes_ Garba a Grinder b�` --- 1 •-- 9 -��'-�__ Lot Size Water}Su I Public S stem and name __ pl?y: - Yom__-= _ 1�Z� ?��_,�ePrivate ❑ Character of soil to a depth of 3 feet: Sand❑ ;-Silt,❑_„_.Clay.-,❑ —Peat❑_—Sandy Loam C]_ Clay Loam Hardpan E] I Adobe 'X 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.) 6N NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 6\ PACKAGE TREATMENT [ ] SEPTIC TANK Size -_g k-571 __ Liquid Depth 31� Capacity 1�-JV_P----- Type �, +�f - Material_,d*-V1' '_.--_ No. Compartments _- Distance to nearest:i We11 -----_________ ----------------------�o undation _Z,09. ---------- Prop. Line _47-1------------ LEACHING LINE [ No. of Lines ---- r--- - _7 _ _.___ Length of each line. P-___t_-___.___--- Total Length �__.-______ f --- ------ D' Box �t'_' _-- Type Filter Material ` Depth Filter .Material f-____z"------_-------- _____ Dista n a nearest: Well ' " -------- Foundation ---------Foundation ' - Pro ------ Property Line -��---------�•----- SEEPAGE PIT Depth _ _._r Diameter .--- Number _/ �. --- Rock Filled Yes ' No ❑ r - ------------- Water Table Depth - .- - --------------------------------Rock Size-, r ------------ Distance to nearest: Well ,____._ _________ Foundation1.1410----__.___ Pra :Eine _ J - tp. to.--------•------- REPAIR/ADDITION(Prev..,Sanitation 'Permit# _. t_____________________________________ Date :• ble Septic Tank {Specify Requirements) __.__- � r �� •------------------------- --------------- ----------- Disposal Field (Specify Requirements) �--_- ._ ----------------- ---------------- --------------------------------- ---------- -------------------------------------------- `� -------------------------------------------------------------------------------------------- --- j (Draw existin and required addition on reverse side) ---------- -------------------------------------- I hereby certify that I have prepared this ap'plication�.and that the•work-will be done in accordance with San Joaquin County Ordinances, Std`te Laws, and Rules and Regulation of.the'San Joaquih-Local Health District Home owner or licen- sed agents signature certifies the following: r "I certify that in the performance of the work for which this permit is issued, I-shall not employ anyrperson in such manner as to become subject to Workman's Compensation laws of California.” Signed .. --------------- = Owner �., BY -------- tle s'* 4 ---------- - {!f of t n owner).. r s ---;- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 8Y . - � __ ------------------------- ---------------------------------. DATE ' Yl/y_� -- ILDING PERMIT ISSUED __________________________ ' ` = DATE`------------------------------- ADDiTIONAL COMMENTS ---------------- -------- � _ -- ---- ------�------------ , --------.� •,� „ a 1 -- ----- - -------------------- ----------------------- ---- = ------------------ -------------- ----------------------------------------------------- --- ----- ----------------------------------------- '----------------------------- - - - ----- ------ Fi l In -------- -- - ----------- Final Inspection by: _ "---_ - _ = - -------- ---------•------- ------ -------------- -------------- --.Date _. --- --- --- ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5ML� +�