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FORaOFFICE USE: --------------- ------- -- APPLICATION FOR SANITATION PERMIT (Complete in Triplicate) Permit No. ------------- This Permit Expires 1 Year From Date Issued Date Issued ...�17' Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein a described. This application is made in compliance with County Ordinanc No. 549 and existing Rules and Regulations: :y JOB ADDRESS/LOCATION .___1_�s� _�¢-__- _ - - ---CENSUS TRACT --- ------------ Owner's Name ----- 1 I -- - --Ph ne _!-__�_ Address i ------------- - Cit Contractor's Name .__- - --_ l --- -- - --------------------------- -.License # �_i � � Phone _ 'f�Uqc Installation will serve: Residence X-Apartment House❑ Commercial ❑Trailer Court ',❑ Motel ❑ Other - Number of living units:---I------- Number of bedrooms __ ._1Garbage Grinder .110_- Lot Size Water Supply: Public System and name ---------------------------------------------------------Private [� Character of soil to a depth.-Of 3 feet: Sd' . k an � Silt❑ Clay ❑ Peat❑ ` Sandy Loam ❑ Clay Loam ❑ 4 V Hardpan ❑ Adobe R 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.) NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] \ PACKAGE TREATMENT L � [ 7 SEPTIC TANK-T l Size-------------------------------•---•------------ Liquid Depth Capacity ---------------- Type -------------------- Material--------------------- No. Compartments Distance to nearest: Well _______________ _--__------Foundation -_._____-- - I Prop. Line ---------------------- LEACHING LINE � No. of Lines -------- � `C / /------------ Length of each line--.----/A?----_------- Total Length __L� __.._..-_----_ 'D' Box ---- Type Filter Material _____V........... Filter Material ______'0V _11 } ------------------- ------------- --•---------- i Distance to;nearest: Well - --_------_- Foundation _,32q--- --------- Property Line ----ff"S".'•- I- - i SEEPAGE PITth De _ ___-_ Diameter . Number -.__._---/---------------p ---- - -- - -�� ---- -- Rock Filled Yes Ja No Water Table Depth ------------(7411_1---------------------- •� Rock-Size --------�---------- Distance to nearest: Well _________`[ � ------_--Foundation ___ef�049_f_.- Prop. Line ------------ REPAIR DDIT /� (Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) Septic Tank (Specify Requirements) ------------------------------ ---------------------------------------------------- ----------------------------- ------------------ - Disposal - --------------------------- Disposal Field (Specify Requirements) ---______/a_U_-_-- ------ a ,� _____________________________ f --------_---_____---- Draw existing and required addit-it i_on-____on_____ _____reverse____sid__e__}--------------------------------------------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: "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 become.subject to Workman's Compensation laws of California." Signed ----------------- ;;� ----- Owner - -------------------------/-- -------------------- - BY �' '----------- r -------------------------1____--------------------- Title (If other than owner) FOR DEPARTMENT USE ONL APPLICATION ACCEPTED BY _._ _-_--_____ __ -- ------- _ BUILDING PERMIT ISSUED f ---- DATE __ - `� t -- ---------- ------------------------ -------- -------- . ----- ADDITIONAL COMMENTS ----------- ---�- _ DATE ------�- -�-------- ----------------------- ----------- ----------- ------- ------- -- .. - --------- -- ----------- 1 -- ------------ Final Inspection b --- =------ _ Date _ OA6QIN • 0CaL LTH DISTRICT E. H. 9 1-'68- Rev. 5M - t rr