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°PLICATION FOR SANITATION PE X -------------------- --------��---'-- (Complete in Triplicate) Permit No. /: -- -- ______________ This Permit Expires T Year From Date Issued Bate 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LCLCATION -- ----- --- `' 3------------ --------CENSUS TRACT ------------- Owner s Name d_ - one __ h Address f € --- `` i'------- --------------- City 7 - Name --------- t-'- }�� ---------------------- ----------------- Contractor's �:' - ' ' ' = --------- License # / �' .t-r: __ hone" - f` / , Installation will serve: Residence ❑Apartment House❑ Commercial [Z]Traifer-Court ❑ Motel ❑Other Wateber Supply:IPublicB i5.stem and name of bedrooms ------------Garbage•Grinder _-.________ Lot Size ,:�C. l::_:.��-�-_.� ___._.______.____- of Y ---- --------------------------------•--------- -------------------------o--Private - - Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay a Peat❑ Sandy Loam -❑ Clay Loam ❑ Hardpan Adobe'[, il-1-M aterial ------------ If yes, type ----------------------- (PI'ot 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- Liquid .Depth---------------------.- ---- i Capacity ____________________ Type -------------------- Material---------------------- No. Compartments Distance to nearest: Wel1 ------------------------------------Fou-ndation ------------------- Prop. Line -.--------- _.__.__ - LEACHING LINE No. of Lines Total Length ._:_____________ vv [ Length of, each line- -----------. y 'D' Sox ------------ Type Filter Material ____________________Depth Filter Material ---------- ---------------------------------- Distance ------••-------•--•---------- Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. _------------_---------- -SEEPAGE ----- _-..----- -SEEPAGE PIT [ j Depth --------------- --- Diameter ---------------- Number ------------------------------ Rock Filled Yes 0 No i❑ Water Table Depth ------------------------------------------------Rock Size ------------------------- Distance ------------------- --Distance to nearest: Well ----------------------------------------Foundation -____-- .--- :.--- Prop.. Line ....-:'------=---•- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date '---_----------------__-- 1 Septic Tank (Specify Requirements) ----------------- .. -- _ - -- -----------------•---- -----/------ Dispos /Field Specify R quirpments) -------- 71 -_- --- - = _••- �'�t==- s-'__ F-� , ' sry �t : - -- (Draw ------------------ --- ' 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 Sara Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "l certify that in the performance of the work for which this per�m't is issued I shall not employ an Y person in such manner as to become subject to Workman's Compensation laws of California." Signed -------------------- ---------- ` wne BY - �- / P fi r- ------ ---- ---- -- ---- - ��---- f�rL--�A --��--------- ------- ---Title -- -------- --------- - (If other tha ornery FOR.DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _- -_. e ~------ _ _ _ DATE PERMIT ISSUED ------------------ - -- ----- _----DATE -- - ----- -- - ---------------------------------------------------------- -- -- -------------------- ADB€TIGNAL COMMENTS -------------------- - ------------ - ----------- ------- ------ - --- -------- ------------------------- Final Inspection lay:. ----- -------------------- Date ��_ -~ SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M