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"lk FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT q .......... ................................. �� Permit No. ....�3..�..7.. / ...... T (Complete in Triplicate) " r This Permit Expires 1 Year From Date Issued Date Issued . ...�`.:.7 3 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/LOC o � NSUS TRACT ..............:.. ... Owner's Name ......: .�c. '.. .. ..... .... . . ... '....................................:. . .... P one ......... .............. Address .......... .:..... - :�._..... .. :-� .. City ................................. .. -. Contractor's Name � /.,�... . •.-��i-� �License #c�:�c�.'.�'�'1,�. Phone Installation will serve: Residence Apartment House❑ Commercial❑Trailer Court 0 Motel ❑ Other ......:...................................... Number of living units:_. ..... Number ofedrooms :..,?.Z....Garbage Grinder ...... Lot Size .��-X__./��.................. n Water Supply: Public System and ame .... •�>.....................-.::....................................................................Private ❑ Character of soil to a depth of 3 feet: Sand fl Slit❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ Hardpan ❑ AdobeX Fill M6terlol ............ If yes,type ......................... (Plot plan, showing size of lot, iodation 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 E j SEPTIC TANKM Size..... -(V...XA.. . ..._. . Liquid Depth .....0. /........ a ...... Capacity ..Aa- Q Type �.. .-- aterial`3?'G ......_ No. Compartments ......sem-.......... I Distance to nearest: Well ._-__.- Foundation .1� Pro Line � _j W. . E,...... ------- p. ...................... ` ) LEACHING LI • No. of Lines I....... Length of each line.-.--.................... Total Length T' fel --------------•• ... g ........................... co 'D' Box ............ Type Filter Material ......................Depth filter Material ............................................ Distance to'nearest: Well ........................ Foundation .-.--..._.... .......... Property Line .........................V' SEEPAGE PIT f ] Depth .................... Diameter ............... Number ..:......................... Rock Filled Yes [j No Q� y Water Table Depth . ..........................Rock Size ._.......--------.... .......... ........................................ .. Distance to nearest: Well ........ ..........................Foundation .................... Prop. Line ____ ................. i REPAIR/ADDITION(Prev. Sanitation Peryl& ....__....--.-..I................jDate ..................................) p' .J L Septic Tank (Specify Requirements) - -•. --• ........ ..... ....... ......._.. -•-- Disposal Field (Specify Requirements) ............. . L.. r __Ir.. , ........ -- .... - / ........................................................ .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 Son Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Homs 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 parson in such manner as to become subject to Workman's Compensation laws of California." Signed .--..... Owner i BY ....... ........ .... . ...._.-.._.......-...... (If other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -'-... - ..... .j_. -.-.-_ '` --d..:.......................... DATE .. .'.r... .. = .. BUILDING PERMIT' ISSUED ••. .......................•-•----.--..._.....---•-•--..;.._.-....---�------------=--•-.......:..............DATE -------------•-------•---..._-_...-._-..... E ADDITIONALCOMMENTS .........................................•-----•-----......_.._..-.---------•--.................................:.. -------•------•---•---- ...................................... .............................._...__............ ............. _•..... ......................•----------•-•- ........ ....... .. ............ ... --- ........Date �. ........ Final ....Final Inspection by - SAN JOAQUIN LOCAL' HEkLTH DISTRICT E. H.13 241-'68 Rev. 5M 7/723-M �