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FOR OFFICE USE: APPLICATION FOR SANITATION PE' IT �(�, ` --------------------- ` / � Permit No. (Complete in Triplicate) "'"""""""." --------------------------------- .......... ----------- . ......_..-------- .---- -------------- ----------- . ... This Permit Expires 1 Year From Date Issued Date Issued -. - !L/. K 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 nCounty �rOrdinance No. 554,9/and existing Rules and Regulations: LJOB ADDRESS/LOCATION.-./C . .......CENSUS TRACT ---------------------_-.- Owner's Name •. G-!'l.�-------------------- ---------- ... .... hone Address /� -- ---- -- - Ci -- - ---------- ----------------I.....•........................ ` Contractor's Name ..... - .. ��7 T - - r„J.- ------License # ��1'.��Y Phone -- ------------------•-•-- Installation will serve: Residence P Apartment House❑ Commercial ❑Trailer Court r. Motel ❑Other ----.........................---- ------- Number of living units:.....-L Number of bedrooms ._IV.--_.Garbage Grinder ------------ Lot Size --- Water -Water Supply: Public System and name -------------------------------.._.....................------------- -----------------------------------Private 21--� Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clayi❑ Peat E) Sandy Loam C] Clay Loam E) Hardpan ❑ Adobe Fill Material ------------ If yes,type ---------------------------- (Plot ...._...._.._._......-(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 see ge pit permitted ifUblii sewer is available within 200 feet,) ` PACKAGE TREATMENT [ ] SEP - Liquid Depth c Capacity lelee .. iype . --- Material A—A- -Xe--2 No. Compartments .crC,._------------ Distance to neJest: Well _--------- O ......... ---...Foundation ...."/D-- ........ Prop. Line - -s............ I LEACHING LINE [,Jl� No. of Lines ---...1.............. Length of each line------.`��."--------- Total Length -.;.2ff.............. 'D' Box .-:/....... Type Filter Material ..-S! ..--.Depth Filter Material -"../�----............................. 1 _ A/ Distance o nearest: Well .._.S©'...--._. Foundation _.-_1O._`_.."-.-.- Property Line _...-.---------___ SEEPAGE PIT [ ] Depth --------- - ------ Diameter ---------------- Number ------------ -------.------- Rock Filled Yes ❑ No i❑ Water Table Depth ---------------------Rock Size -.-.---. _._----.- Distance to nearest: Well ..-----------------------------------...Foundation ......... .......... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# -------.------_--------.----- ------------- Date ....._.--.-----.-_-.-._-- Septic Tank (Specify Requirements) -------------------------------------------------------'=:..--------------------------------------•-------------------------- 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 peron in such manner as to become subject orkman's Com nsation laws of California." Signed ._.------ ------- _...-.. Owner By --------------------- - Title6. - - (If other than owner) FOR DEPARTMENT USE ONLY n QQ APPLIC TION ACCEPTED BY - - y ------------------------------ DATE -frf �� +c.... ......----- PERMITISSUED -- --------- ---- -- -- DATE - -- ---- --- -----..I AL COMMENTS ---------- --------------------------- -- ------------------------------------------ ------ - -"- ............--...... _ - - ---- ------- - -- - - - --------------......_--------------------------------------- ----- -------------- ---------- ---- - - -- - -------- ---------- -----------------------------.... - FinalInspection by - - -- -- - - -- - - - -------------------------------........------------------Date --�1- - - <.:--------•----- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M