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'FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT j 3 Permit No, ---- ------------------------------- -------- ------------ (Complete in Triplicate) ---------- ---------------------------------------------- Z Z '7/ Date issued -.. ---------- This Permit Expires I Year From 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/LOC-AT N _�_%_�_ - -�-- . -- --- --� --------------------------- --CENSUS TRACT _646--------------- Owner's Name ---- `----- --------- - - - - -----Phone -- ------------------------- -•----- Address --------------� - 7 ------,?----- -------------`---------. City ---- ----------------------.-----------•-•-------------- Contractor's Name 111_1 511 �`k -License # �iO-:3 Phone Installation will serve: ResidencetV partment House❑ Commercial [-]Trailer Court :❑ T I Motel ❑ Other -------------------------- _ ------ Number of living units:------- Number of bedrooms --_Garbar ge Grinder ------------ Lot Size ' Water Supply: Public System and name ___-_____________________________________. -'- - -- ----- _____Private [ F Character of soil to a depth of 3 feet: Sand❑ ilt❑ Clay E] 'Peat E] Sandy Loom ❑ Clay Loam:❑ Hardpan.[ Adobe F1 Fill Material]------.._.__ If yes,type -------------------_-______ �t - V i (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,J L fr PACKAGE TREATMENT [ } SEPTIC TANK'[j� . Size--- _��`_j�- .- -�-- Liquid Depth -7---------------------- Capacity 28DT e __ Material---L� �- � No. Compartments '� Distance to nearest: Well --------F-6---------------------Foundation ----------- Prop. Line 5'___._____:__._.... LEACHING LINE [4r No. of Lines ---------/-----------`Length of'each line------1;?p-..---------- Total Length __ ...i............ 'D' Box -------{_--Type FiltertMaterial ---- - �------Depth Filter Material --------J-1---- -------------------------- Distance to nearest: Well J,6P!---------- Foundation -1-0-1------------- Property Line, __ -_________---:..__ SEEPAGE PIT [ ] Depth _-- ---- __ Diameter -_--__ _ -__ Number ------1:3? --------------- Rock Filled Yes No i❑ Water Table Depth ----------- ------------------------------Rock Size O ------- Foundation ---1 a------•--- Prop. Line --•------- Distance to nearest: Well ____________�_. -]-._ REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------=----------------------- Date ---------------------•------------) 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 Mules 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 ---- ---- Owner ��} f la---- -0 Title, BY ------ --------------------------------------------- -- - (If other than owner) FOR .DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -- - ----- --- - - `--------------------------------------------------------------------------• DATE ----------------- BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------- ----------- ADDITIONALCOMMENTS ----------------------------------------- ------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- ---------------------------------------- ------------------------ -------------------------------------------------------------------------------------------- -- ----------- -------------------------------- Final Inspection bY- ---- -- -- --- - ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M