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APPLICATION FOR SANITATION PERMIT � ............... ...................................... '...rr '� it __.. Perm No 1....__.�� {Complete in Triplicates .__..._..._..--•.............. .. . ......-----..._.. r ......................................................... This Permit Expires I Year Frorn Date Issued Date Issued . Application is hereby mode to the.San Joaquin Local Health District for 'a permit to.construct and install the work herein described. This application is made In�Jc'om €iance with County Ordinance No. 549 and existing Rules and Regulationst f06.ADDRESS/LOCA I /..: ! .. ...... .....................CENSUS TRACT 1 Owner't Name .. ........... -..._. - ..Phone 3.'`.. .............. Address'.... - _....City �... ..... ........... .................. Contractor's Name .._.. '' " . ................ ........................ ------.License # ......-----..........: Phone ............................... Installation will serve: Residence Apartment House(] Commercial ❑Traller Court ❑ Motel ❑Other ........................................... _.._ Number of living units:_.:__ ge Grinder ............ Lot Size ............................................ Water Supply. Public System and namer of bedrooms ^•...._.... ....................Private ❑ Character of-Lsoil to a depth of 3 feats Sand❑ Silt 0 Clay Ej. Peat❑ Sandy Loam ❑ Clay-Loam ❑ Hardpan ❑ Adobe Q Fill Materidl •:... 1f yes,,type ............... ............ 5 (Plot plan, showing size of lot,.locatlon•,of system in relation to wells, buildings, etc. must beplaced. on reverse side.] � NEW INSTALLATION: (No septic tank or seepage pitpermitted If public sewer is available within 200 feet,j PACKAGE TREATMENT I ] SEPTIC TANK i j Site..................... ..... Liquid Depth Capacity .................... Type ... Material::::: ........... No. Compartments ..................... Distance to nearest: Well - ....:. ......Foundation .:...:. Prop. Line ............... LEACHING LINE._ { l No. of Lines ------------------------ Length of eachline............................. Total Length ......................... I D' Bax ter Material - Depth Filter Material Fil - ---•.. ........................:...... a Distance to nearest: Well ....... ..............:.. Foundation .. Prope . Une SEEPAGE PIT .Depth . Number - - Rode Filled .Yet No Water Table Depth ---- :....................................Rock Size a............................... Distance to nearest, Well ..........................................Foundatio ._.._.............. Prop. Line .................... I REPAIR/ADDITION(Prev. Sanitation Permit# ........_.. ._......... Date ...............................j Septic Tank (Specify Requirements} ........... r � � ............ �.;f:•�-.r...f.....__... --- Disposal Feld (Specify Re uiremnesl ......�/........... .. .. ___._ .... .................. . .......................-:..:.....:........................................:..:._.:. ------------- ... .._..........................................------................. .......... .... »: {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, Stole Lows, and Rules and Regulations of the San Joaquin Local Health Dishid. Hoene owner or liter. sed agents signature certifies the following: "I certify that in tine erformance of the work for which this permit is issued, 1 shall not "lloy'an' y pw9on in such manner � as to bec 'e o r s-�e1 ensation aws of California." f a t Signed ..............------------------•-:--- --....._......... .-------- -- ................... Owner By .........:. : ...'... .. :........... .. ...._.:.......... ..:............. ...:....•Sitio .....--•--• :........------ ....... ..... •......... F ` pf other than owner] - _ FPA DEPARTMENT-USE ONLY. APPLICATION ACCEPTED-BY ........_:...... .... --•---................................................. ................DATE ....: .. ..................... •--•--•--- BUILDING PERMIT ISSUED ...................................................... ......... .::.....................................DATE ...................................... .... ADDITIONAL COMMENTS ...........................•----•--••-----.._.........__......._..-_.........................................._......._....._.....................---.....__.... ........................................... ------------- --- ---•--------•-----.._.....----........"AN -------_...-..--- --= ----.--.-.----.--. - ----------•••------.._.... ._.........__. Final inspection b--y' ...............,'- - ------••-••--•----------------•-•-.......Date .... . ��.. .. ....----- EI 13 24 1-60 �• 5HUIN L L HEALTH DISTRICT 8/74 31�4y''� • - LYhI a