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FOR OFFICE USE: a APPLICATION FOR SANITATION PERMIT (Complete In Triplicate) Permit No. ...................•- This Permit Expires f Year From Dat*Issued Date Issued ............... Application is hereby made to the San Joaquin Local Wealth 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 � ..... .....................CENSUS TRACT Owner's Name ........... . --•...................................... ..................Phone ... ....................... Address p city ..,/ Contractor's Nome :........'r�..... I { License # ...... 6, hone Installation will serve: Residence 0 Apartmen House Commercial {]Troller Court 0 Motel []Other ............................................ i !� Number of living units:....___ Number of bedrooms � .� Garbage Grinder ...:........ Lot Size ...�.._...*44 .................... Water Supply: Public System and name ........................................................'....................................................private E Character of soil to a depth of 3 feet: Sand k] Silt❑ Clay ❑ _Pe'a't❑ Sandy Loam ❑ Clay Loam D Hardpan ❑ Adobe p Fill Material ............ If yes,type ............... ............ (Plot plan, showing size of lot, location of system in relat€oh 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,) PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size------Loo.:._.-------•.............. Liquid Depth .....C2® ...... Capacity Type ... Material_________________ No. Compartments � Distance to nearest: Well ....................................Foundation ...................... Prop. Line .... LEACHING LINE [ ] No. of Lines.......-Z............. Length-of each llne�k...70............ Total Length ...... ........� 'D' Box _J--.---- Type Filter Material ....................Depth .Filter Material ............................................ Distance to nearest: Well ........................ Foundation Property Line .......... ............. V1 SEEPAGE PIT [ ] Depth ----_- Diameter ................ Number ----------------------- Rock Filled Yes ❑ No ❑ . Water Table Depth --------------....... -------------------_--.Rock Size ............................... Distance to nearest: Well ----------------------------------------Foundation _................... Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permit# --------.---_--------------�............. Date ---_--.._... ................ Septic Tank (Specify Requirements] ................................................. ........... , DisposalField (Specify Requirements) -----•..........................................:.................•---.........................................._........... ........ . ----------------- -----------------------------------------------------------------------------------•-----•---•--...-..------•- ----------------- ------------- ---------------- ------------.._...----------------------------------------._............ _-_----------------.. n ._..� {Draw existing and required addition oreverse side) i I hereby certify that 1 have prepared this application and that the work will be done In accordance with San Joaquln< County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:Distriet. Name owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner as to bec�b ect to Work tnpensation laws of California." Signed . l ....... Owner p/ pf� By __l`1r � �`1 .1 ' --------------------- Title %.+ ..._ .j :. �CJI4CJ.C/�?. Of other than owner) FO&DEPARTMEN USE ONLY APPLICATION ACCEPTED Y BUILDING PERMIT ISSUED :...... ----- ------ ------•--- --------------DATE .......:::............ ------------- ADDITIONALCOMMENTS .. ---...---•-------•-- - ------------------------------•. -•-•- ......_..___.......... -------------- ------------------- ----- -------- :.'. ....... -- ................ --I---- -- - - -I----------------- ... ------------------ ...... ----------------- ........... ............. Final Inspection by: 1.� • --- --- .. ... ......... ........----------------- ...------ ------Date - .`. , ..... ' � 13 21� i—bl3 �v. �� SAN JOAQUIN CAL HEALTH DISTRICT 8/74 3M l