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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT (Completer Permit No. ..in Triplicate) .._. .............. ........................... _. _ .a .. . ..... This Peerr�lt Expires t Year From Oate Issued Date Issued ._7:71 Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work heroin described. This application is made in co pliance ith unty Ordinance No. 549 and existing Rules and Regulations. / 3y ,3JX io JOB ADDRESS/LOCATI N/lei ci_l�.. _!r ..l -ur b - � .. ........CENSUS TRACT .......................... Owner's Name .......... .... . rr ...........-----•-•----•----•........... ........... :................Phone ................................. Address ._.�.331 -._ �r city ........................... .... .. ............. Contractor's Name ......_�....�._____�`'' = � i'.'""•'t License .1P3 Phone .............................. Installation will serve: Residence p'Apartment Houseo Commercial ❑Trailer Court Motel ❑Other .----•--•-•--•---•----•-•...............••-- Number of living units:-.._.j_.... Number of bedrooms .2......Garbage Grinder ............ Lot Size .. ?- .......................:............... . f Water Supply: Public System and name .Private 4s.. Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat.❑ Sandy Loam ID Clay loam Qom-. -fz, Hardpan Q Adobe 0 Fill Material If yes,type V► (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) NEW INSTALLATION: t (No septic tank or seepage pit-permitted if public sewer.is available within 204 feet,) PACKAGE TREATMENT [ } SEPTIC TANK ] Size................................................ Liquid Depth ......................... - I Capacity ------------------ ----- Material..------------_-. No. Compartments Distance.to nearest: Well ------------------------------------Foundation ---- ................. Prop. Line ...................... LEACHING LINE I [ ] No. of Lines ------------------------ Length of each line............................. Total Length ............................ 'D' Sox ..---:----- Type Filter Material ....................Depth Filter Material ............................................ Distance to nearest: Well ------------------------ Foundation ---------- ......... Property Line ........................ SEEPAGE PIT [ j Depth -- --------------- Diameter ...----- ....... Number ....... _ ... ................_ Rock Filled Yes ❑ No 09,EPA Water Table Depth -------------- y ----------------------Rock Size ................................. I , Distance to nearest: Well -_--------------=----------------------foundation --__................ . Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# --------.------------------___..:--------- Date ..........................,....... ) Septic Tank (Specify Requirements) -•••--------------------------------•---- --•--- . . Disposal Field (Specify Requirements)' _-- - _ �- :... .............. -- •- -------------------••---.........._.............._..I..........._........ ?'(Draw existing and required addition on reverse side) r 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. Horne owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any person in such manner as to become subject--to Workman's Compensation laws of California." Signed --------------------------------------- -='-----•----•--- ---- -------.....--------- Owner BY ------------------------------ --------------- ----------- .--- --- Title ' (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- -• -- _--- - -• ------- DATE .._ .. .Z....7.�r.:.: BUILDING PERMIT ISSUED ........... = -------------------------- ------------------------•--.._...DATE ............. ADDITIONALCOMMENTSi---------------------------------------------------------------------•-------------------------•------------------------•---------------------- ------------------- ---------------------- h ---------------------------•--------•-----............................•......... ......................_........ ......... ----- �---------------•---•--------- ----_-----•------ - ..._. � .. "r...........................................................__.. ................Date ......_.. .Z ... ......... Final Inspection by: ...... iii 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT $/7!i 3N . I