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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT { ---------------------- Permit No. . '/O�S_a2,. (Complete in Triplicate) _______________ This Permit Expires 1 Year From Date Issued Date Issued I! 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 o. 549 nd' xisting Rules and Regulations: _ e� JOB ADDRESS/LOCATI N I1_�2_ __ , _------ r�-_--� -----"CENSUS TRACT -------------- ------- Owner's Name WO4 ---------------------------------------------------------------------Phone Address --------------------------- City " -------/7------------- -- --- - ' ------- Contractor's Name,____/?1&��--- `lop ------------------- --- License #/� � �Phone 3C�-�- 04' 14;;� Installation will serve:- Residence A-A-partment House'❑ Commercial ❑Trailer Court ❑ 1 Motel ❑Other -------------- ---------`------------------- Number of living units:----/--- Number of bedrooms -1 Garbage Grinder Lot Size li ( Water Supply. Public System and name -------- ---------------- -----:----------------------------------------------------------------Private Is Character of soil to a depth of 3 feet: Sand'�� Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan Adobe-❑ Fill Material ------------ If yes,type ____________________________ (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 p blit sewer is available within 200 feet,) -= d PACKAGE TREATMENT SEPTIC TANK Size-- Li { I - ------ . quid bepth -------- ..----- Capacity _ _ Type Material 4.017 No. Compartments ___ _._....... _ 1 Distance to nearest: Well ___ _ ________________Foundation A1,19------------ Prop. Line ---�� .. ..__. LEACHING LINE141 No, of Lines __ Length of each line_- Total Length YN D' Box Type Filter Material Depth Filter Material /_ __w� _____._...-`...:_... Distance to nearest: Well _K. Foundation A�____________ Property Line , ____.__.. SEEPAGE PIT Depth _A_f-____ Diameter.J �------- Number __----�..r_ _ o \ ` Rock Filled Yes N �'] - ------------ P -- _0-----------•-----------Foundation Water Table Depth --_-��-- Rock Size Distance to nearest: Well _-�_ ''_ -""Prop. Line ___________ _ ________ REPAIR/ADDITION(Prev. Sanitation Permit# ------- ----------------------------------- Date ----_-------------------------_._-) Septic Tank (Specify Requirements) ------------------------------ ------------------------------------------------------------------ ------ " 3 l T - Disposal Field [Specify Requirements) ----- ---------------------------------------------------- -- -------------------------------- -- --- ----------•------ ------- � ------------------------------------------------- -------- ------ -----------------------------------------------------------------------------------------------------------------------'------ - ---------------------------------------------------------- (Draw existing and required addition on reverse side] 1 hereby certify that I 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 Local Health District. Home owner or licen- sed agents signature certifies the following: I "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 become subject to Workman's Compensation laws of California." Signed -- ---"---- -------- Owner BY --- ---------- Title .��_-------------------------------------- (If other than owner) - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- DATE --------------------------------------- BUILDING PERMIT ISSUED ------ ------'---------- ----------- -- -----------------------------------------------------------------DATE ------------------------------------ ADDITIONAL COMMENTS ------ --------I + ---------- ----------------------------------------------- ------- --------------------------------------------------- ---------- -------------------------- t ------------------------------------------------------ - --------------------- - - -------------------- --------------------------------------------------------------------------------- --- - =------- Final Inspection by: ---- --- --- -----.Date " p SAN JOAQUIN LOCAL HEALTH DISTRICT - - o E. H. 9 1-'68 Rev. 5M,