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r FOP OFFICE USE: • ',� APPLICATION FOR SANIT06W OERMiT (Complete In Triplicate) Permit No. ..................... ......................................................... // ?S ......................................................... 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 ..... _.. /. `-. , ......................CENSUS TRACT .......................... Owner's Name .... .. }............. -.-.Phone ....--------•-----•----------------- ; Address /..��.. ... ... Cit ... •............... ..........._..... �......... y y Contractor's Name . .. . ..... .... r.A,.. .License d~�/`.3�. phone ��,��,.�� Installation will serve: Residence Apartment House❑ Commercial []Trailer Court 0 Motel ❑Other ............... ......................... l Number of living units:...... Number of b' roo ......Garbage Grinder''-Lot Size ./� ._ �� .... r - , Water Supply: Public System and name ..... [/. ...............:...................................Private ❑ Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam [] Clay Loam C] Hardpan [] AdobeFill 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: INo septic tank or seepage pit permitteedd'if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ) SEPTIC TANK Al/S� �E 1 ] Liquid Depth .............:............ .� Capacity .. . ..... ....... Type .....:......,....... Material:...................... No. Compartments ..................... Distance to nearest: Well . ..................................Foundation ...................... Prop. Line ............ ....... LEACHING LINE No. of Lines __... Length of a ch li Total Length ... _ .. �. 'D' Boxes . Type Filter Material �De Depth Filter Mate , ��............................. v.. Distance to nearest: Well�!L¢. 1iliC Foundation ._.fi ..•........ Property line .......... j SEEPAGE PIT+! Depth _.. Di eter 1?1?..`..... Number ...._ .................. Rock Filled Yes� No []� ✓✓ �` Water Table Depth..-t-.---------------------------------Rock Si;e ..C.....r..........-- �. Distance to nearest: Well Foundation .f.._. Prop. line ... ._�..... '• REPAIR/ADDITION(Prev. Sanitation Permit# ........................................_.. Date ..................................I Septic Tank {Specify Regvirements) ..... .............. ..._._.. Disposal Field (specify Requirements) .. I .... _:...................... / ........I....................................................................................._.... ........: ............. ............I................. ...I......... ............ .. . - ---............-•---...--............. --.--- ... -•-- -._.._......._...------....... ; (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will its done int accordance with Son 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 &boll not employ any person in such manner as to become subject to Workman's Compensation laws of California." j Signed .... ......... .... Owner By .... ... '....... ... .... Title .................. j (If other than owner) OR DEPARTME USE ONLY ! ` APPLICATION ACCEPTED BY ... . - DATE . a F BUILDING PERMIT ISSUED ........................ . ... ....DATE . ..............................-......... i ADDITIONAL COMMENTS ............. ..... ...........................1.... .... ..._.._.._... ......................................................... �...1.. ----------- ------ .................. •. ............. /.......... r .................. Final Inspection b : ............. ... -_----Date . -.r. _r-- • P Y --------- --- -- --• ----- ... ..---- SAN JOAQUI LOCAL HEALTH DISTRICT E. H.13 241-'68 Rev. 5M 7/72 3 M