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FOR OFFICE USE: 1 APPLICATION FOR SANITATION PERMIT --------------------- (Complete in Triplicate) Permit No. 70---6 ------ --------------- This Permit Expires ] Year From bate Issued Date Issued _f 13 -_7 4 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. 544 and existing Rules and Regulations: JOB ADDRESS/LOCATION .. - --------� . �-- CENSUS TRACT _ --- --= - - -- --------------------------------------- - Owner's Name --- ------- ----------- ---�--------` -��':�- -----• Address .__ ---- --------- ---Phone ------------------------- _ -4 _ ------ f " Contractor's Name - ---------------------- City , �---- ---- --•---------- - ------------- -------------- -------------------License # ------ -:----- ----- Phone ------------- Installation will serve: Residence ®Apartment House 10 Commercial :(—]Trailer 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.❑ Clay ❑ Peat[l Sandy Loam ❑ Clay Loam;❑ Hardpan❑ RAdobe ❑ ;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 seepage pit permitted if public sewer is available within 200 feet,) r PACKAGE TREATMENT ) ] SEPTIC TANK I 0 h � �] i [k] Size---- __ -------- -------- Liquid Depth -11--------------------.. Capacity r- O Type Material-ti v_-------- ` ' No. Compartments " 1 Distance to nearest: Well -----± -13 `---------------------Found ation ... d_D-------------- Prop. Line --- -•-•:----------- LEACHING LINE W{l No. of Lines --------- T le Filter Material I of each line--- - ------------- ----- data! Length :-- e'- �} YP '_______Depth Filter Material __-_ - $ --r _ - ---•----------------------- Distance to nearest: Well _ --0 _---_--_-__ Foundation __�-�-_________----- Property Line _.�_.. ._ ` SEEPAGE PIT 1 , Depth --�": ---------- .Diameter ��---------- I Number _.______.---_-------------- Rock Filled Yes ® No .10 Water Table Depth ----i ------------------------• Rock Size Distance to nearest: Well -.I__ "----------------------------Foundation .- -- __-_-_ . Prop. Line ------ REPAIR/ADDITION(Prev, Sanitation Permit# -------- ----------------------------------------- Date -----------------__-_-- Septic Tank (Specify Requirements( Disposal Field (Specify Requirements) .--- ---------------------------------------------------- ------------------- - ---------------------------------- ------ --= ----- -.`-erg - e..- l ------------- ------------- -- ----------------------------------------------------- --- --- ---- --- _______ (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 I 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 t t in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to be a bjec ton5= laws of California." Signed - ----- ---- Owner BY -- --- - -- - ---- ---------- Title (If other than owner) ---------- - ------------------------------------- - I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- � - I: --------------- _ _ '_T_�_ BUILDING PERMIT ISSUED -- - ------ ---------- --------------------------------------------------- -- -- --------- ----------- -----. DATE --------- ------- ------DATE -------------•--------- ADDITIONAL COMMENTS --- --------- ---------- ---- - --------------------------�---------- --------- - . - . _. _ ----------• - -- ---- - -- -------------------------------------------------------------- - - : -_ ---- --- -0- -- ---------------- -------------------- --- -- -----------------------------Final Inspection by - - -- -t---- -- -.-- ------- ------ (- ------------------------------------------------------------------------Dae -- -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT E, H. 9 1-'68 Rev. 5M.. 4