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POR OFFICE USE: APPLICATION FOR SANITATION PERMIT ---------�-<�/v.--- • -- ��--�"�------- _ - . G/ (Complete in Triplicate) Permit No. - - - - -- ----------------------------_ .. This Permit Expires ] 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: - A0-- ----- -----------------CENSUS TRACT -------------------------- JOB ADDRESS/LOCATION ._/�----��--f�_�-,� �,'��-.�---- � Owner's Name ----- J:0--'J------------------------------------------------- -------- ---------? Address ---- -------------------- 122L __r city 1-- PhonPhe one_ -/-----------------_------- Contractor's _..^ _t _ •Jl 1-Contractor's Name ----------- ------� -c -----------------------------------License # a 7 Installation will serve: Residence n-4-artment House�❑ Commercial :❑Trailer Court ❑ f Motel ❑Other -------------------------------------------- }}�,�yy ,,!! Number of living units:--------- Number of bedrooms _2------Garbage Grinder -ye.5___ Lot Size ls,�_°'_ lUdX?'-� Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private i Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe- Fill Material �-d�Y ---/ - If Yes, type _ e ____--_ __-_______- (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 permittedifif public sewer is available within 200 feet,) PACKAGE TREATMENT D( SEPTIC TANK'[ ] SizetO Y9k_ .X_�V------------------ Liquid Depth --��? ----•-,- Capacity .J-a�&d------Type 'r-a-C_ MaterialCompartments _41-------- � Distance to nearest: Well -------�Q__1___________________Foundation ___=_� __�_ ___ Prop. Line ___,�___----------- Q LEACHING LINE No, of Lines ---_ --____- Length of each line_-____ _J-- -7. Total Length -- --z ----_____________ 'D' Box ___ 6-'> Type Filter Material _ _J _4<k Depth Filter Material ----K-l_------------------------------- i Distance t nearest: Well ----�1''---------------- Foundation ---- --------- Property Line- --e --l-_______--:_--_ SEEPAGE PIT [ Depth ___ (Diameter 3_--------- Number —-------------- Rock Filled Yes ®--_'No C3 y I Water Table Depth -------_P-/_- ----- ------------------------Rock Size --- II2--- ----------- _ Distance to nearest: Well ------- i ------- ----------------Foundation Prop. Line ---4_..... _...-_ REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------=----------- Date ---------------------------------- Septic ----------------------------- -Septic Tank (Specify Requirements) --------------------------------------- ----------------------------------- Disposal Field {Specify Requirements) ------------------------------- ------------------------------------------------------------------------------------- ------ ------------ ---------------------- ----------------------- ---------------------------------------------------------------------------- -------------------------------- (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 certifies the following: "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 ----------- ---------------------------------------------�-----,-------- Z--- --------------------- Owner ,, a BY -------------------- --- W N..4,X. - ------ Title ----- --- L --------------- ---------------- (If other than owner) fOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ' 7 a '-------------- • DATE' `_ - ------------- BUILDING PERMIT ISSUED ----------------------------------------- ----DATE ------- ----------------------------------- ADDITIONAL COMMENTS ------- -------- --------- ------- --------------------------------------------------------------- --:____ _______ __: --- -=v�.e------- - �i�---------------------------------------- -------- --------------- -- - - ----- ------------------- ------------- - - -- - = FinalInspection by: ----------' .e'-- ------- -------------------- -----------.Date ---- F___' ? SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. .9 1-'68 Rev. 5M