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FOR OFFICE USE: `.PPLICATION FOR SANITATION PEP 'T ------ - --- ---- - ---------- {Complete in Triplicate} 1.. Permit No. This Permit Expires 1 Year From Date Issued Date Issued 5/ 01-7 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/LOCATION 4 _ .> - -5 t -- CENSUS TRACT ---- ---------- a ; Owner's Name .-- --. ._..- Phone .. Address ..- . Cit - >> ---------------------------- ' ' f�� Phone -------- - ----------- Contractor's Name ---- -- --------- License # - -��--.. Installation will serve: Residence [Apartment Holu�e'❑ Commercial railer 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 E] ClayC/eat❑ 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: (No septic tank or seep Ie pit permitted if public seer is available within 200 feet,) PACKAGE TREATMENT [ I SEPTIC TANK'[ Size ,�.3 X-h ��,--------------- Liquid Depth .. � ___..._.-..------ Capacity T Cc- ype�c�a.�� Material No. Compartments -�-._-._.-.--_ r 4stance to nearest: Well --._....._i0a-_.._.._...___foundation __ ._-14?_`...._.. Prop. Line ....s._---_-.-.--- LEACHING LINE [ o. of Lines ______---- Length of each line------7-Y_------ ------ Total Length _-.j-S.Q_.._.._...--_-- ' ._ r. 'D' BoxType Filter Material .._-_Depth Filter Material _____)_T.------- -- ......,-------------- s Distance; nearest: Well ..__A.-D.4--r___.__ Foundation ---'�.�._1_--------- -- Property Line -._._._._.__. SEEPAGE PIT [ Depth _.' S _ Diameterpp ._ 'b`___...__ Number -----------vt. Rock//Filled Yes [7�No i0 Water Table Depth ............_ a.. --------------------- ------- Rock Size ... Distance to nearest: Well ---- ------Foundation ------ Prop. Line ---5--------------- -REPAIR/ADDITION(Prev. Sanitation Permit# ..----...-_r------------------------------ Date _.--.._-------.._____.._______----1 Septic Tank {Specify Requirements) -- --- -- - --_---------------- ------------------------- ----------- ------------- ----------------- ___--------------- �0 Disposal Field (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 County Ordinances, State Laws, and Rules and Regulations of the Son 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 Com ensation laws of California." Signed -- -- ----- ---- ..... ...... . . ---------------------------- Owner _0L_ BY . .. ..... ... ...... +- Title _.......:.. �- +. '�f "....... ...... ------- ... (If other than owner) Q FOR 'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -.. ------------ ---------------- DATE .S'" r,� --------- --- ------------ -- BUILDING PERMIT ISSUED ----------------- --------- --- ---.......----....__..._ ---- ....DATE ...... - ------ ... ..... ADDITIONAL COMMENTS -..... ........... .... .. -------------------------- ..---------------------- - -------------- ----------- ------------------------------ --- ------------------ .G�"� - ( } Final Inspection by: .... . ......Date .y rC�. ------------ f}. . SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M