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FOR OFFICE USE: APPLICATION ICOR SANITATION PERMIT 7- ►. . Permit No. ..................... F (Complete 1n Triplicate) •..................... ...................... ........... Date lasued :/..—... Z �7 .. ......... This Perntiit Expires 1 Year From Date loomed Applicotion is hereby.made to the San Joaquin local Health District for a permit to construct and install the work herein described. This opplication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATi N ..1..io. .. _...._ ................... . . ........... ..... .... ` -..................CENSUS TRACT ........... t !c.Q..-.�..c.1..�. - ..�..-.-......n._...-p..� ............. .4...�...... ....Pho.n..e...............................................Owner's Name ...... .......... s-:o. .......... City . .......... Phone .................Address Contractor's Name .G., ........License .. ...................._. . installation will serve: Residence [Apartment House(] Commercial❑Trailer Court It Motel ❑Other Number of living units:-....--- Number of bedrooms . Garbc a Grinder Lot Size ....... .......... 01 Water Supply: Public System and name . -----------...................................:._....................................................Private ®� ~ Character of soil to a depth of 3 feet: Sand❑ Silt❑- Gay ❑ Peat❑ Sandy Loam O Clay'Loom Hardpan j] Adobe ❑ Fill Material ............ If yes,type ............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed onreverse 51 0. .NEW INSTALLATION- (No septic tank or seepage . it .permitted if public sewer Is available within 200 feet) PACKAGE TREATMENT I f SEPTIC TANK;r1]X S1ze_ ��...�.. ,Y.��. ....... liquid Depth .... ............... Capacity Type ._...----- �!. _ ._... T e Material__ No. Compartments ...•••- ..... Foundation ._...tp............ Pro Line ... .... Distance to nearest: Well �� .. _ _ E p. .. ............. 00 LEACHING LINE No. of Lines ..__:... Length of each line..._._4V. I� ,.�-...-_. •-........... .Tata1 Length ---La'..•.Q............... .J 'D` Box ..../...... Type Filter Material _...S.. ..----Depth .Filter Material .............................. r•----_... ...SDistance to nearest: Well -------- FoundationProperty Line SEEPAGE PIT [ Depth .......dam . Diameter Number ......... .............. Rock Filled Yes- No . a a { Mater Table Depth PQ.........................stock Size 1. -- .- -..••.... Distance to nearest: Well ............1- 10 0..............:....foundation .........n.:1...... Prop. Line ..... ..�. • '? REPAIR/ADDITION(Prev. Sanitation Permit# .... ----------------- Date .................................. Septic Tank,(Specify Requirements) ......-.............................................................................. ---------._....... ............................... Disposal f=ield (Specify Requirements) --------• -...•----------------------------------------------•-------- ..........................................—............. ----------------- F ........... ----------------......... ...... . .-._.-.___.._.-_______..-__-..-_._.-.•-__.--.......___........___......_____,____.._....._....-......_..........._.......__....._,............... .-........... r (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be clone in accordance with San Joaquin I County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.Distdct. Hone owner pr 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 { as .to become subject to Workman's Compensation laws of California." I i Signed ------------- ------------------------ - ----------------- Owner BY Title _ ti`4'..--...... (If other than ownerl FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .__C'.._�3 ._._d3 •----- ------------------------------------- ..-:--- . DATE ./`./. ��------ ....---'. BUILDING 'PERM#T' ISSUED - :`:.:. ---_--- � ......::.............. DATE...:":........_.__._..._...__... ADDITIONALCOMMENTS.---•---...------•-- ---------------•----•-•---•---••--------------.._.... -----------....-............... ----------------- ......................... _ -•--------- --- ----- -------------- ---------- ----- --------............ ....__._.._.------- ......... Final Inspection by. ..L�'O'--•• _------- Date ../- . EH 13 24 -1-68 Rev. 5R SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7li 3M