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.a FOR OFFIdt USE: APPLICATION FOR SANITATION PERMIT Permit No. . (Complete In Triplicate) .................... ................................ Date Issued :.. . .76. ..........v--- ............ This Permit Expires t Year From Onto Issued Application is hereby made to the San Joaquin Local Health District.'for a per to construct and install the work herein described. This application.is.made:.in._compliance with..Courity`.Ordinance NO._549 and_existing_Itules.and Regulations: 4 -JOB ADDRESS/Loc N ..�r��..__7�. ........................................CENSUS TRACT .......................... Owner's Name ....... ...... ... ,...... .....--•..................:....:...•--..........Phone .................................. Address f..r� .r.., ._. max- .. ...... City .... `'-aC'c ... .................. .............. _ .._... / 8 � Phone Contractor's Nome _ . License ......... .. .Installation will serve: Itesidence,Apartment House Commercial❑Trallet Court 0 " Motel 0 Other .. Number of living units:-----. mbar of bedrooms ...d, /.......Garbage Grinder ............. Lot Size ..... .... Water Supply Public System and n ..Private. Character of soil to a depth of 3 feet: Sand❑ —slit-0—Clay-0— Peat 0-—'Sandy Loam oy Loam Hardpan Q Adobe 0 Fill Material .... If yes,type............... ............ (Plot plan, showing size of lot, location of system in relation to wells, buildings; etc. must be- placed tin reverse side NEW INSTALLATION: (No septic tank or seepage pit permitted"if public sewer is available within 200 feet,) PACKAGE TREATMENT .[ ] SEPTIC TANK f I Size....................................:--------... Liquid Depth .................... ,••••- Capacity _-_.._.._. Type ." `- .Material.................... No. Compartments EDistance to nearest: Well --------•---•-•.....................Foundation ...................... Prop. tine ......._____......... 4 LEACHING LINE I ] No. of Lines -------------- ------ Length of each -Mw............................ Total Length ' ' DBox Type Filter Material `� Depth Filter Material ...- Yp 4 ..... Foundation. ................._.__ Property Line Distance to nearest: Well ..... ... Pro .............•-•--...... SEEPAGE PIT Depth ____ _______________ Diameter --._._.......... Number ... ........_.._.........--- Rock Filled Yes ❑ No (3 ` Water Table Depth -•--------------•---------•-------•-•• ..--•--:Rock Size •e-----•----- ............... Distance to nearest: Well ---------------------------------•- foundation ------............_. Prop. Line ...................... REPAIR/ADDITION{Prov. Sanitation Permit# ---_----- _---•......-- ••-•---- Date ..........f.1•--- .......•,--•-••1 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 11011111- sod agents signature certifies the following: N 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 .......... --------------------------------------- ------------------------------•-----i Title . .............. . (if other than owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,BY ................ •--- -- — DATE BUILDING PERMIT ISSUED _-.------{------------------------ --..............DATE ....-_-_..__....__-_----..__ .............. ADDITIONAL COMMENTS -----------_-------------------- ------- --- ------•----•------------- ------ •-------• ----.....-:------- -------...........---•-- ••-•-----•- w. finalInspection by- --------------------- ..-. ----•-----........----------------......-------................__._Date ... ....------ -- 775 ---.. iii 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M I