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FOR OFFICE USE: yPLICATION FOR SANITATION PERA� \/ (Complete in Triplicate) Permit No. ___-____-_..... ..... This Permit Expires 1 Year From Date Issued Date Issued [-J v Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is �m.7ade in compliance with County Ordinance Orrrdinance No. 549 d existing Rules and Regulations: JOB ADDRESS/LOCATIO ._rte- _ 1-..-_ g _/ C G _PYhditJ__CENSUS TRACT ..____.___.-__..- Owner's Name ---- - '- - -- 2f, C---- '------------------------- '--------- . . Phone --�--j---------------------- �. Address ..._....- - 1.. - - ------- ------_ City Z-`----------------------- Contractor's Name ... '.. - c:rc - .License # -Phone - Installation will serve: Residence ❑Apartment Ho�use�❑� �C�ojmm rcial ❑Trailer Court Motel ❑ Other Number of living units:._..._ Number of bedrooms --.';-'---Garbage Grinder - - - Lot Size _... -_< -- -------_-_ Water Supply: Public System and name -----------------------------------------------------------------------------------------------Private Af Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam F1 Hardpan ❑ Adobe 0 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,) PACKAGE TREATMENT [ ] SEPTIC TANK: Size. y'al 5 / '` 0 W c � �- --�--�--X..-------------- Liquid Depth ---Z----------------- Capacity �`.,�...QC eTypeO-r5raz-s. -- Material 'iNo. Compartments ...- ,.._....... Distance to near t: Well -...._5L?---/....-------- --Foundation -..1 _-- ------ Prop. Line ..:�-.�.:-._....- LEACHING LINE [ KNo. of Lines ----------- Length of each line__.....f_60..-.._. Total Length ---/-----_- Q 'D' Box ._ .__ Type Filter Material .....�S.P------Depth Filter Material ----- ----------------- ....... F�{ — Distance to nearest: Well _...fi�D-- --------- Foundation ----- -------:.- Property Line ---s_-...-------. 1 i SEEPAGE PIT [ Depth ----- Diameter . .'"._._. Number ----_..7�------------_- Rock Filled Yes [I No Water Table Depth ____-__-f��-� ------ -- --.-Rock Size ------ -=�3 -- Distance to nearest: Well ._.----- P.CI_r-- .... ..._;_.Foundation 1..4'------ -------- Prop. Line ------------- REPAIR/ADDITION(Prev. Sanitation Permit# ---_-._.-....._.._.-...._.-....._ Date ---------------------------------I Septic Tank (Specify Requirements) DisposalField (Specify Requirements) -------- ----------------------------------------------------- ---------------------------- ------------------ ------------- - ----- ---------.. ....................------------------- (Draw existing and required addition on reverse side) 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 .� as to become subject to Workman's Compensation laws of California." Signed ..... - ............ - 4 1 � n bwner By -------------------------- - ---- 1 - - Title ....�?��'�Ka ��z - - -- - (If other than owner) � . y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY .. - ------ -- - - -- ----- .._...- - -----. DATE .y 6'Zy BUILDING PERMIT ISSUED --- ------ -- --- -- - - - -- --..DATE - - -------- - ...... -- ADDITIONAL COMMENTS ... - -- - --- -------------------------------------- -- ..._ ----- - - -- -- ---------- ....... - --- - - ---- ----------- ---------------------- -- ---.----- ------------------.._...--- ---- ------------ _.._.-.. - - - - ------ Final � � �y Inspection by: - -------- -- ------------ ------------------------------ ---------Date - .- ---- -------- --.... SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M