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FOR OFFICE USE: APPLICATION, FOVSANITATION PERMIT ------------------------------------------------ Permit � (Complete in Triplicate) --------�--•----- 22- ------------------------- ------- This Permit Expires ] Year From Date Issued 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: � t Al ie E ' ?` �-0- 3f JOB ADDRi_SS/LOCAs IONAdgKO- e:.er-ere�X --� --- � ' ' �---CENSUS TRA CTr __________________________ Owner's Name '----= --Pftone------------------------------•----- Address �/ ' f'- '� USF=l9/e.� �Y_e _. itY '�'--t'�-- --------------------•-- ...... Contractor's Name ---3_�f__ r. -------License # ,s' /_, Phone Installation will serve: Residence [] Apartment House,❑ Com rcial : railer Court ❑ Motel ❑Other __ G' _ -- --------------- Number of living units- 4 of bedroomst -,-Garbage Grinder -----____:._ Lot Size __________________________________,---_.. Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay/K Peat❑ Sandy Loam -❑ Clay Loam ❑ � Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ----------_________________ Q (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,) fr PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] -------- i _ -2----------------------------------- Liquid Depth ----- �------------ Capacity ._ �3____ Type SizeMaterial--------- ------------ No. impartments Distance to nearest: Well ------1_?29 ?__�______________Foundation _____ --_________ Prop. Line ____- ... LEACHING LINE [ ] No. of Lines --___/_--_ g r ________ Length of each line�p----------------- Total Length ____�d______.......-- /� , rs 'D' Box Com/- Type Filter Material/ Depth Filter Material �----------------•-_-/_____...... r e, Distance to nearest: Well _��C3 --------- Foundation 14--____________-Property Line. �________________ SEEPAGE PIT [ ] Depth ____, -___ Diameter _9_3---- Number ---------�-------- ----- Rock Filled Yes No C3 Water Table Depth -------�_3-1----------------------------Rock Size --- _ _ _ -- - r � Distance to nearest: Well -------zap ____----------------__Foundation __,e,'Q_---_---. Prop. Line �— ------- REPAIR/ADDITION(Prev. Sanitation Permit# ________ ----------------------------------- Date ____--________________.__________) Septic Tank (Specify Requirements) ------------------- ------------- ---- ..--------------------------- DisposalField (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 Son 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 as to becom ct to Workmams omp sation laws of California." Signed -- - - - - -- -- • --- --- - --- - ---- - --- ---- Owner By --- -- -- �--- ------- Title Se c (If other than o, FO)1(/DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- - • ____- DATE -- �=- �, ------------------- BUILDING PERMIT ISSUED ------ l ------------------ --------------------------------------------DATE --- --- ---------------------------------- ADDITIONAL COMMENTS -- --------------Z. ----------------- --•-- \-------------------------- a----------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- - - - ---- --- -----------------------------------------------------------------------------------------------------------------------------------•------ `------------------I---------- ----- Final Inspection by: --------.Date -..__�©. --� -� I SAN JOAQUIN LOCAL HEALTH DISTRICT If E H. 9 1-'68 Rev. 5M