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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT -- iL 7/ 7 �`_L -:----"--------- ------------------- Permit No. - (Complete in Triplicate) Date Issued ---- This Permit Expires 1 Year From Date Issued Application is hereby made tc 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 Ordinance No. 549 and existing Rules and Regulations: J �y� -___CENSUS TRACT 5 ________________ JOB ADDRESS/LOCATION Z____ �� Owner's Name _ Phone ------------------------- - — Address l�ro ------------ --- -------- . City Contractor's Name - dyed - License # /40S� Phone _ _ __ 4d Installation will serve: Residence KApartment House❑ Commercial ❑Trailer Court ;❑ ; Motel ❑ Other ------------------------------------------- Number ------------------------------ ------ -Number of living. units:---4----- Number of bedrooms _______Garbage Grinder ------------- Lot Size __ �""` -�----• Water Supply: Public System and nam_ e ---------------- ------------------------------------------------------- ------Private Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ Hardpan K 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,) s;. PACKAGE TREATMENT ( ] SEPTIC TANK' i.� S�ize____ � ./-�-�- Liquid Depth __ ___ �---------- Capacity 4 __Girl Type - --"-=` Material`�.1�_n. �_e _ No. Compartments ___ __..... Distance to nearest: Well ------ 1----------Foundation _-fid_- Prop. Line ___ �_7i'.------ ' ' f. r _ Total Len LEACHING LINE No. of Lines _.___ _.� .-____- ength of�;each line'-40v----- - - Length -�� --------------- Y P D' Box .___ - f e. Fil#er M'aterial'�1 ��-.___Depth Filter Material _ _______________________..._____.____._ nearest;T __________ Foundation �------ Distance to Well -- Q ' i r `-GB----------- -- Property Line _____ ..----- SEEPAGE PIT --- Depth -----_-_ Diameter .1 ________ Number __._. :______/�._/�__�___ Rock fF Iced Yes No ❑ r f-----Rock Size f, -_- - -- -- �a. Water Table Depth -- a ♦ r Distance to-nearest:_ _Well ---- ----t-------------•...Foundation -----------. -- grope Line -- -- --•-- r , ",REAIR/ ADDITION(Prev. Sanitation Permit# -______'------------------------------- -- Date ----------------- __---------.-�]; � Septic Tank (Specify Requirements) --------- ------------------------------1- -------------- r= `--------------- ----------------------------•-- >s Disposal Field (SpecifRequirements) --------------------------- ----------------------------------------------------------------------------------------------------------- y ------------------------------------ - ------ ---------------- ------------------------- -_________________._,_________________s_7________-____________. ___________________________________ _,,,�,� _ ..n_ . --------------------- (Draw existing and regUired.addition on reverse side) - p, I hereby certify that I have prepared this application and.that the work`Yvi11 be done„in accordance with S i .Joaquin County Ordinances, State Laws, and Rules and Regulations}of:the San Joaquin Local Heal th.DistricHome 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 4 mrpI y any person in such manner as to become subject to Workman's Compensation laws of California.” Signed " l l-i`' " ----- Owner l3i c� BY -------------- Title ------- --11 h+a , '(If other than ner) r _ FOR DEPARTMENT USE ONLY ��F# '< DATE -_ �..�� - APPLICATIONACCEPTED BY --------------I------------------------•---------------------- -------------- BUILDING PERMIT ISSUED -------------------------- - ------------------------- ------------------------------------ --------- ----DATE ----- ------------------------------------- ADDITIONAL COMMENTS _--------- `________ ,}______ _-_ U_"_`___r' Q1 6�� ------��-"-1--- ------------------- --------------------------- ----------- - - ------------------------------------------- -------- ----------------------------------------------------------------------------------------------------------- ---------------- -� --------------- Final Inspection-by: ------ ----------------------- ---.Date _-.-i/� SAN JOAQUIN LOCAL HEALTH DISTRICT "F. H_ 9 1-'68 Rev. 5M h'3 0