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FOR OFFICE SE: APPLICATION FOR SANITATION PERMIT / Permit No. (Complete in Triplicate) t L=1 ---- ------- ------- -- �., ..,,_._.....�,,.,.,.�._..�.Date Issued ---�--= ------------- ------------ _ -------- ----- This Permit Expires 1 Year From bate issued for a e"work he-rein PP AI location is hereby made to the San Joaquin oan compliance with Health District i tOrdinance permit and existing Rules tand hReguldtions. described. This application is made in P fi `/4 4_k_`r-C' ENSUS TRACT ----- __JJOB ADDRESS/LOCATION �t O � _ - ------- ------ Phone ----------------------r--- ner's Name ----------- .C -------- ---- City ---- -------tle _, 1 Address v� License #/ - (19 � _ Phane �= �y`� Contractor's Name ----------- C--- ` l,C u� 0�^'� Installation will serve: Residence 2-11(partment House❑ Commercial ❑Trailer Court' i,❑ Motel ❑Other -------------------------------------------- ------- ------- ----- Number of living units: ._;_ ___ Number of bedrooms -- -----Garba_ge Grinder ------------ Lot Size ----------------------------- -" ---_.Private ❑ water Supply: Public System and name ------------------------------------------------------t, Sift Clay ❑ Peat❑ Sandy Clay Loam:❑ Character of soil to a depth of 3 feet: Sand'❑ Hardpan ❑ Adobe E] Fill Materia __"_- _-_-- If Yes,tYP� buildings, etc. must be placed on reverse side.} (Plot plan, showing size of lot, location of system in relation to wells, � NEW INSTALLATION: (No septic tank or seepage permitted if public ewer is a pailable within 200 feet,) Size _9 _-� � r Liquid' Depth --------- - + PACKAGE TREATMENT [ SEPTI.C.:TANK N i+ ------ Na.+ �_ � Material---------- -- Compartments o�.- ---------- Capacity _��_� ------- TYPex=-=-----• - -- - r r: -+ � .- -4� Foundation _.� Prop. Line .:1 Dis ante to nedtest:Well __--_---j-ll-------------- IF r ` Total Length -------- ACHING -----• k No of Lines _- --------- ---- Length of each line------- --•- g LEACHING LINE j . f� 'D' Bax .__ __.___ Type Filter Material 1_ --c0-a--Depth Filter Material ___ .__ rT------------------- Di.-once to nearest: Wel{ ----6d-------------- Foundation ---1`�1__--__.- --� Property Line " - -- SEEPAGE PIT [ ] Depth Diameter ------------- Number ----------------- Rock Filled Yes ❑ No .❑ -- -- -- - --- - --- Wafer Table Depth Rock Size --------------j_- Dist nce tnearest. Well =. --Foundation ----------- -------- Prop. Line ------ --_-------- REPAIRfADbITION(Prev. Sanifiation Permit - ---- Date . ;;_. _ } I � Septic Tank {Specify Req�irements} -- ------ ---- ------ --------------- ------- ------- ------- --------------------------- ------- ---- •.•-------- ------11 1 =-- -------- I -,-=----------- Disposal -------- Disposal Field (Specify requirements) ---------- ---------------- --------------------------------------------------- 1i - ------- ---------------------=--------- ---------- -_ --- # ------ -- --------------------- c "- (Draw existirig and required addition on reverse si e) Jhereby certify that 1 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 Locaj Health Dislricl. Home owner or icen- sed agents signature certifies the following: person in such manner 'tl certify that in the performance of the work f r which this permit is issued, 1 shall not employ any i as to become subject to Workman's Compensation laws of California." ' t � Owner Signed - - -- -•- -- - --- --- _ - - -- - -- - _•Title ...._.� . _ By (If other than`ow'nerl- J L r FOR DEPARTMENT USE ONLY ^rr x i DATE _ �.Z-�,7 =---- -- APPLICATION ACCEPTED BY, ------------------ "" -------------_------------...:�_�.._pATE------------------------------ .- BUILDING PERMIT ISSUED ----)-------------- ---- j------ ADDITIONAL COMMENTS I --- -------------- - - - --- _ _ _ ---------- ---- ---------- r -- s• -- ---------------- - l� __ _ - --- ------------------ ---------- -- ` ---D t �` Final Inspection Y .. SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M r• _rte. 4 -�