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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT .... lCompleto in Triplicate) Permit No. ...7 5:3.5... ;._.......:.................. - This Dote Issued /—/i s Permit Exp€res 1 Year From Dole issued ..._.._. ...---- Application is hereby made to the San Joaquin local Health District for a permit to construct and Install the work herein ' describer!. This application is mWe in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRf j ..I...............CENSUS TRACT SS IOCATIO / ( r'.. .......... Owner's Name p! -. . I• ....................... Phone ..8.... Address _.. .q-7----- -- ----------------- - - ----...1..._.........••.--_..,...........'City . .. ........ `• .......... Contractor's Name ............. License ............... Ph F installation will serve: Residence❑Apartment House Commercial Moller Court 0 Motel ❑Other Number of living units:_.. ..... Number of bedrooms --..... Garbage Grinder .......I.... Lot Site ........................... ................ Water Supply: Public System and name -•----.....-•......................_....._......._... ....................................................Private Character of soil to a depth of 3 feet: Sand❑ Silt Q Gay ❑ Peat❑ Sandy loam.❑ Clay Loam❑ Hardpan [j Adobe 0 Fill M6terial ............if yes,type............... ............. f G (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,) PACKAGE TREATMENTSEPTIC TANK t � . site................................................ Liquid Depth .......................... Capacity,-------------------- Type .................... Material................. - --- No. Compartments Distance to nearest: Well ............ O s .......................Foundation ...................... Prop. Line .................... LEACHING LINE [ } No. of Lines Length of each line....................... Total Length m D' Box Type Filter Material ..Depth Filter Material Distance`to nearest: Well ........................ Foundation ........................ Property Line ........................�i SEEPAGE PIT O Depth -------------------- Diameter .---•-........_-. Number ...--- Rock Filled Yes ❑ No C3 Water Table Depth _...............................................Rock Size ................................. Distance to nearest: Well --------------•............ ............ .................... Prop. Line ....:................. REPAWADDITION(Prev. Sanitation Permit i ..-•-- ........ �•............... . .... Dat ............ r Septic Tank (SpecifyRequirements) �. r .............. ...... ................................ Disposal Field (Specify Requirements) .-- ................................................................................ .................................................... f •_•__-._••_ __._•___________--------------------------------------------.---------------------....... _ .. ...... ..........___•............................ ......y......._.................................--_..... i (Draw existing and required addition on reverse side) , I hereby certify that I have prepared this,application and,that the work,will be -dans in accordance with Son Jo"vtn County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or licen• sed agents signature certifies the fallowing: "I certify that in the performance,# the work for"which this permit is Issued, I shall not employ any person in such manner as to becom ct #porkSn Compensation laws of California. Signed ------ -- ----- --- Owner By ---- "------------•-•-------.... J'itle ......... ...... -------- (If other than owner) ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTE=D BY -- --- -• ------ ._:/ -:............... DATE ...............__..._........ BUILDING PERMIT ISSUED .-----------DATE ............ .......... ........ F AbbITIONAI COMMS - " --------------------- ------------- -------------------------------- - -- --------- -----•----•- ---------------••- ------- . --------- ................... ......--- ---....,_._....----------........ ............ ---•--•--•... --.final Inspection by: . ------------------------...----•..................................................Date ... ... Y..."7-.. _......._ . I ' EH 13 2h 1-68 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT $j7h 3M I