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FOR OFFICE USE: 4PPLICATION FOR SANITATION PI JIT ---- ---------- --------•---------- - -------- 4 (Complete in Triplicate) -.Permit No. ------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued 3..-- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein j described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: I JOB ADDRESS/L7 Wit• '- p-- ----------- --..__CENSUS TRACT `f ------- Owner's Name OCATION -• -•--r��h=, Phone Address .--- --- -r-67• --G-------` City ----------------------------------•------- -- --------- -- Contractor's Name -------------- -- . ---7.- -- , ----.License #/fie __ Phone ----------------- -------- Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ Motel ❑ Other ------r/¢oe_lk Number of living units:_--- Number of bedrooms _____------ Grinder ------------ Lot Size .....______________________ Water Supply: Public System and name _______________ _ ___ Private [ ` Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ i K Hardpan ❑ 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.) (�1 NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [SEPTIC TANK' ! ,,,/ 7 --'--• Liquid Depth --1�------------------ C � J Sized--��---'�--..r-- Capacity -- w-Irl k- Type��Material e 0170.1 .,.___ No. Compartments _. .............. Distance to WeaWell --- ---------- ---------------- ____/ ___________ Prop. Line --- .. ----------- .. i LEACHING LINE [i No. of Lines ........J-____________ Length of each line_..-_4,0----_--__.____- Total Length ----------- 'D' 'D' Box`71--0_ Type Filter Material -_____ _e! _t._Depth Filter Material --------- _r>____---__________ ° Distance to nearest: Well ---------- Foundation _____________ Property Lines.-r-_ -- -_- SEEPAGE •-- - . PIT { Depth -_--- Diameter ---____.______ Number ___- _---------------- Rock Filled Yes ❑ No i❑ • Water Table Depth ------------------------------------------------Rock Size -------------------------------- Distance to nearest: Well ------------------ .Foundation -------------------- Prop. Line _...._....... ........ REPAIR/ADDITION CPrev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------_) t Septic Tank (Specify Requirements) ------------- --------------.----•-----------------•---------- I� Disposal Field (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 1 as to become wbject Workman's Compen on laws of California." Signed ........ -- ------•- Owner By -- -- C�._c. Title ------- r-a�------------------- - (If o er than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- ----- ------ -------- ----------------------------------------------------------- DATE a----:---- I BUILDING PERMIT ISSUED ------------------------ -- - ----------------DATE -------------•------------------- -- -- I ADDITIONAL COMMENTS --------------------------- - E t ----- ---------------------------------------------------------------------------------- �---- �� _.. .. Final Inspection by: ------Date -- �-- '- -- -------------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'66 Rev. 5M