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~ FOR OFFICE USE: APPLICATION, FOR SANITATION PERMIT __ X33 Permit No. .----- Date Issued (Complete in Triplicate) ------------------------------------ This Permit Expires l Year From Date Issued C Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins ly PP the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. , 4'po - ----CENSUS TRACT ------------------ i JOB ADDRESS/LOCATION - .!- �-- -T�-�--C��-IZ��d-1---�f�,�-------�- -'------ - Owner's Name .,G -------- r �� --- --------- -Phone' ------------------------ p P� ------------------------ ------ Address --'��4- --- -- --�� -- ----� � ��=-'--- - ------------- City - - - Contractor's Name --- 1, -- s90 �-------------------------=--------License #/ f-17. _ Phonee -- Installation will serve: Residence [impartment House[] Commercial:❑Trailer Court [1 Motel ❑ Other ----------------------------------------• -- r Number of living units:--- Number of bedrooms _�-----Garbage Grinder .'- Lot Size - ` 1- -- � Water Supply: Public System and name -------------------------------- --------------------------------------------------------------...-------------Private' r, Character of soil to a depth of 3 feet: Sand'[] Silt E3Clay E] Peat❑ Sandy Loam -ElClay LogmX 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 seepage pit permitted if public sewer is available within 200 feet,) f �' Liquid Depth , = 9 PACKAGE TREATMENT [ ] SEPTIC TANK, S/e -_._ __ ---- -- Ca acit / Type //- aterials -�--- No. Compartments -- _---..--•--- le Distance to nearest: Well -__------��------------------Foundation --149- _---------- Prop: ---Line ------------- No. of Lines -----{---------------- Length of each line r LEACHING LINE , ��----------- Total Length,-�-�OD............ 1 f 'D' Box -- Type Filter Materia - -Depth Filter Material /Q/tr�l1 ----•--•-•-•• 9 ° � -T„_------------` Jr Distance to nearest: Well - may' �-------- Foundation ± ----------- Property ' . .... 'Line . ............... -_---- Number __.---______- -- Rack Filled Yes ' No SEEPAGE PIT Depth pt��------ Diameter r fr �Water Table Depth 2�--- ---- Rock Size/ '� i .01 Distance to nearest: Well -----------------------Foundation ----- Pro A.•-' Line _4... ..----•--... REPAIR/ADDITION(Prev. Sanitation Perm -•------ ------------------------------------ Date ---------------------------------- Septic ---;--------------•--------------Septic Tank (Specify Requirements) - ----------------------------------._----------------- ---------------------------- ------------------------------- Disposal Field (Specify Requirements) ---------------------------------------------------------------------'------------------ --------------------------•-- // Y i ---------------------------•_.----_------------------_-------------------------•-----..---------------_--------------_------------------_------------------- (Draw existing and required addition on reverse side) j !' 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 f as to become subject to Workman's Compenspflon laws of California." Signed ---------------- --------- ----- ------------ ----- ---------------------- Owner BY - -------------- -•---------- ------ - -- - ------------ ------------ Title -----� I� o�--cy"-- �- ---------------------------- (If oth an owner) ENT USE ONLY. APPLICATION ACCEPTED BY ----------_ _ /`-"Z� --�.l-'--------. ------- -- - - DATE /.- BUILDING PERMIT ISSUED ------------ -- - DATE A IT �dAL CO �IV,I NTS --_{� --- --- - - ----- - - ---- ------------------ -- ----------------- �D,Dp JJ L-- - -------------------------------------------- ---- -------------- -- - ----------------------- --------------------- --- ------------------------ ------------------------------'-------------- --- = Final Inspection by: -- ----- ````''�� ,Date - ----- ----=.z>f---- -------- SAJOAQUIN LOCAL HEALTH DISTRICT } E. H. 9 1-'68 Rev. 5M