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FOR OFFICE USE: iI i! �4PPLICATION FOR SANITATION PE''_!IT -------- ---------- -------------- x (Complete in Triplicate) Permit No: . - This Permit Expires 1 Year From Date Issued Date issued .--y"-3_:-_; i , Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herei described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: II � � d -- CENSUS TRACT JOB ADDRESS LOCATION, Owner's Name =" - - - --.Phone ------------------- ------------ Address - -- ---------- City r Contractor's Name ------ his<- '. �.; ' ------ ` � c _ -- Phone -__.License # Installation-will serve:-•--T-y - --Residence- Apdrtment House'❑ Commerciai-:[ETrailer-£ourt--G Motel ❑ Other - Number of living units ..... Number of bedrooms __4---_--Garbage Grinder ------------ Lot Size ---- --------- -------- '- --------- Water Supply: Public System and name ------------------------------------ _Private Character of soil to a depth!,of 3 feet: Sand❑ Silt I-] Clay ❑ Peat❑ Sandy Loam• Clay Loam:❑ depth,of an Adobe-D Fill Material ------------ If yes,type (Plot plan, showing sizeoLf 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 1 PACKAGE TREATMENT [ 01 SEPTIC TANK 11 Size---------------------- ------------- Liquid Depth -----------••--------- - ld Capacity ------------- ----- Type,,-,------------------ Material------ ------------ No. Compartments ---------- -- •• -•- Distance to nearest: Well` -- ---------------------------------Foundation ---------------------- Prop. Line .------------------ .... LEACHING LINE [ ] No. of Lines -------------- ___ ---- length of each line_..._ __ - _----______._ Total Length g -----. 'D'y Box ------------ Type Filter Materials_---_=.--____-__Depth Filter Material -----____.- ............... Distaste to nearest: Well -__-.--_--_----_-__--_-=,Foundation ----.____-------------- Property Line SEEPAGE PIT [ ] Depth -------------------- Diameter --- ------------ Number .-__.__- _--- Rock Filled Yes ❑ No C]t. Water Table Depth -------------------- -----Rock Size r Distance to nearest: Well -------------------------------- Foundation ---------- Prop. Line,-----------•---------_ REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------- Date ---------`--5-------=- 1 f Septic Tank(Specify Requiremtints)------------------------------- sal ,--------;---,---sal Field (Specify Requirements) -:----" !n _;J _ r - "-- ------- - -------------- --------� ` � - = -�-- - ------- !� .Z;S' i Draw eting and required addition on reverse side) I hereby certify that 1 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 as to become subject to Workman's Compensation laws of California." d :. Signed Owner BY k --------------- -- =� -- Title 4' (If other than owner) :6 > FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------:-5'---------------------------------- - --------------- - ---------- -- -------------• DATE _...-�------------ --------- - -------- BUILDING PERMIT ISSUED " ------------------------ ------ ---------------- -DATE ------- -------- ADDITIONAL COMMENTS _;! a ---- - -..', - - ---- ------------------------- - --------------------------------------------------------------------------- -- -- ; ----------------------------- ------------------------------------- Final Inspection by. =` --------------. -.X� ---.------------------------------- ---- --- Date - J_------- ---------. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M