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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / (Complete in Triplicate) Permit No: - ------------------- -------------- --------------- This Permit Expires 1 Year From Date Issued Date lssued 1G-2 a_-1! 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'Ordinarice No. 549 and existing Rules and Regulations: rTION 1 ;t �JOB ADDRESS/LO " - - ------------------------- __ _ ENSUS TRACT ------ Owner's Name�!-- l� - - --- ---------------------------------------- - - - ----•---- -------------- one ----` �j--------_------- --------_------- Address s -- ----- - - Cit --------------------------------------------------- Contractor's N z ---- -----License #1dV�8�---- Phone ------------------------------ Installation will serve, Resi ence [Apartment House'❑ Commercial ❑Trailer Court Motel ❑Other Number of living units:------j---- Number of bedrooms -- __---Garbage Grinder -_C/---.- Lot Size - o.?'7,---&_7/41Fo 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 ❑ 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 see age pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT C4 f l SEPTIC TANK' ] Size S-/r JD-,�'S_ �' `-- ----------- ------- Liquid Depth -�---------------------- Capacity �----------•--• Ca acit ++ � - p y 1��"p----------- Type " Material__ja:�. ,No. Compartments -Z--_.__-_-.---:-•.- Distance to nearest: Well _--_----dr_a ------------------Foundation ------/p_---------- Prop. Line _---- -.:_.._.__" LEACHING LINE [ No. of Lines -------------- Length of each line-------75'__-"".-"-_ -- Total Length _ ir..._.. 'D' Box _- -"-".6 Type Filter Material --_.S,R: -----_Depth Filter Material __-"_""_""_"_______________________ —tea r : Y f --------------- Foundation .----1-0-------------- Property Line. ------- -------. -- j t Depth ce to Barest- Well "�____.__ � - [ p ------ . er.z_� _/�""" Number -"____ -.-- -__-__ Rock Filled Y. No .i❑ r .. .. .I Water Table Depth ----------------- "_""""._Rock Size I��-.-X✓�- ------- :.. t Distance to nearest: Well -- --- ------Foundation10--------- Prop. Line -------------•-------- REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------'------------- Date ----------------------------------- Septic Tank (Specify Requirements) -----------------------------------------------------= y ------•-------------------- Disposal Field (Specify-Requirements) ----------- -- ------------------------ ---------------------------- Septic ---------- -------------------------------------------'-..._ ._ . -------------------------- --------------------------------------- (Draw existing-and-required addition on reveise side) 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: r "I certifylthat in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become sub)ect to Workman's Compensation laws of California." Signed------ Owner _ .� BY ` __ •- -------- ----------------- Title (If other than owner) � � I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- D ------------------ DATE - ! BUILDING PERMIT ISSUED ---- - DATE -----:'------- ----------------------------- ADDITIONAL COMMENTS -- `wC ----& ' -- i � ----------------------- :-- ---------- ------------------------------ -- ------------------ ------------- -- ----------------------------------------------------------------------------------------------- ----- ---------------------------------------------- ,,y Final inspection by: ------------------------------- Date!Imo--" ' SAN JOAQUIN LOCAL HEALTH DISTRICT E.H. 9 1-'68 Rev. 5M, 3