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FOR OFFICE USE: (' PLICATION FOR SANITATION PER, S ------------------------------ Permit No. {Complete in Triplicate) =------------- --------------- •-----•--------- " Date Issued •----- ----------------_--------,---- This Permit Expires 7 Year From Date Issued 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 mad�ey in compliance with County Ordinance No. 649 and existing Rules and Regulations: JOB ADDRESS/LOCATION ....... OG w � � 'r� - LC--- � .------ Owner's - -Owner's Name ---- -. x �--:----- ----------- -------------------Phone -----------•------------------- .--- Address ------------------------------------------------------•------------------------------------------------- City ------------------------------•-•------"--------•---•---•-----------•--•--- Contractor's Name __ �_A*7__�.-- _4--'�*!Al-------------- ---------•License # 6"_,1 __ Phone ✓�_�3.�"_f�'7/ Installation will serve: Residence ❑Apartment House❑ Commercial []Trailer Court ;❑ Motel ❑Other --- Number of living units_____________ Number 'of bedrooms ------------Garbage Grinder ------ ----- Lot Size ------------------- ------------------------- Water Supply: Public System and name ------••--------_------•-•--------------------------------------------------------------------------- ---------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat E] Sandy Loam Clay Loam,[] 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.) ` NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) y PACKAGE TREATMENT [ SEPTIC TANK Size____ q 'Depth4 Capacity J 4. =:: Type Material----- ®A'S_.:--- No. Compartments' ---+ ... r4 tante to nearest: Well ________________-Foundation ____-�" ----------.Prop. Line --------------- LEACHING LINE [ No. of Lines - /_________.__ Length of each line.______60�"___._ ----- Total Length --- --------------"--.-- 'D' Box ..../----- Type Fitter Material a.P.0 _Depth Filter Material -------- 4___ _ .. Distance to nearest: Well :�_/l'-'.--------- Foundation A� ------------- Property Line- --------------- SEEPAGE PIT [ ) Depth --_---------------- Diameter ----------__"_-. Number ---------------------------- Rack Filled Yes ❑ No Water Table Depth . --.- -----•-----------" " -----------------••------------Rock Size ----------------•---•------------ \' Distance to nearest: Well --------------------------------- ..Foundation -------------------- Prop. Line ----------—...__-- 0 RI_PAIR/ADDITION(Prev. Sanitation Permit Y# -.---------•-------------------------------- Date --------------_•-••-----.-.--- -.-) Septic Tank (Specify Requirements) -------- ------------------------------------------ -------------------------------------------------------- ----------•-- ----------- DisposalField (Specify Requirements) ---------------------------------------------I--------------- ---------------------------- ------------------------------------------- --------------------------------- ------------------- -------------------:------------------------------------------•----------••------------------------------------------- ----------------------------- ---•--------------------------------------------------------------------------------------------------------•------------------------------•-------••------•------••------ (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 1 and Regulations of the San Joaquin County Ordinances, State Laws, and Rules 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 _._ ._r� -•--•-----------------•--------- Owner By ---- ----------- -- -- Title (If other t r) FOR DEPARTMENT USE ONLY , APPLICATION ACCT=PIED BY _.__. I `_. _.-. ------------------------------------------------------------- DATE BUILDING PERMIT ISSUED ------------------• --------------------- ----DATE ------------------------------•----------•- ADDITIONAL COMMENTS ------ --- --- ------------------------------------------------------------------------------------------ --------------------------------------------•• -- -------------------------------""-------•-------------••---------- ----------------------- --- - -------- ---------------------- ------ - - ---- -------------- —��i _ Final Inspection ------------------------••------Date --- - ---- - ----- ---- --- - . - r� SAN JOAQUIN LOCAL HEALTH DISTRICT F- H 9 l-'68 Rev_ SM