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v FOR OFFICE USI:: • A APPLICAWON• FOR SANITATION PERMIT 4 --------------------------- ------ ----- ._ �' _Q.__....., (Complete in Triplicate) Permit No. - - ------ -- --------------=----------------------------- - --------_--------------------------------______________- This Permit Expires 1 Year From Date Issued Date Issued 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. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ---'- - - ------- --- G OL• .---. ��-�N5US TRACT --------------------------- Owner's ------------ ---- >.----.Owner's Name -------- --- --- +- ---- 7-2-4----------------------- -------------Phone -`f-" -------�---- Address ' r- ------------1 C �p --------------------- Ci p l --- --------------------------------------------------- Contractor's ------------------------------------------ ------Contractor's Name .. License #o77 Phone c� 3 `j Installation will serve: Residence *partment House❑ Commercial :❑Trailer Court ;❑ e .- Motel ❑Other -------------------------=---------------- d r Number of living units..--/'---- Number of bedr oms �------Garba a Grinder --------- _ Lot Size _.__ .____ _._ ------ Water Supply: Public System and name --------f '�L�_____--C-'--------6_--- � �'1---------------------------------------------------Private EJ 1 Character of soil to a depth of 3 feet: Sand'❑ Silt C] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:❑ IHardpan ❑ Adobe.2 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.) ��1• } NEW INSTALLATION: [No septic.tank or seepage pit permitted if public sewer is available within 200 feet,} PACKAGE TREATMENT #[ I SEPTIC TANK [ ] { 5ize-__---------_---------------------------------- Liquid Depth",-------------------------- Capacity - --- Type -------------------- Material---------------------- No. Compartments ---------------------- Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ----------...__....... e- I. LEACHING LINE [ No. of Linies ------/-------------- Length of line----�d-�.-_...----- Total Length .__ P-�._..._....__ +� 'D' Box ----- Type Filter Material ___ ______ ___Depth Filter Material __/T-_-----____________________________ • Distance-to nearest: Well ------- _._ ndation ____ --------- Property Line ___�___--------------- SEEPAGE PIT Depth ... Diameter __________------ Number --------.-._ ------------- Rock Filled Yes [ No Water Table Depth r� -- -----------------------Rock Size -----sz---------------------- i - Distance to nearest: Well esl4 l-�_:� ______Foundation __1 0._r______ Prop. Line � REPAIR/ADDITION(Prev. Sanitation Permit# _______________________ ------------------- Date ---------------------------------- I _____________________ ____I wf Septic Tank (Specify Requirements) ___.___._________________________________ __ -------------------------------- ..__,.. -- ---- -------------- -- --- ,� a 3 . Disposal Field (Specify Requirements) _____ ____ i - ----- �----- -- E � i ---------------------------_----------------------------------------------------------------------------------------------------------------------------------------------------__------------------------ ---------------- ______________________________________ ____________________________________________----------------_--------------------------------------------------------------------------------_-----------__ ------------------_ (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 County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature•iertifies the folowing: "1 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 k BY - �---- -------- k� -- Title I (If ot.er than or'ner.f t t _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.; BY a *—j---- _ . ------- ----------------------- DATE --- ---. BUILDING PERMIT ISSUED ------ ` ---------- -- --------------------- ------------------------------- - DATE ------------------`___------ ------- ADDITIONAL COMMENTS --------------------- s „� r d ----- I ---------`------'t--------} ------------- ---------------------------------------------- ------------------ --------------------------------------------- ------ ---- - - -------------------------------A -- -------- - - - - - - ---------------- -= --- - ------- 2 Final Inspection by: ---------- -----------------------------Date ------------ -- ------- SAN JOAQUI LOCAL 'HEALTH DISTRICT 1 ' E. H. 9 1-'68 Rev. 5M