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FOR OFFICE USE: + APPLICATION FOR- SANITATION PERMIT ---- ----��'-�--- (Complete in Triplicate) Permit + p Year From Date Issued Date Issued _ ----------- Tis Permit Ex fires 1 Y 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 Co my Ordinanc4e No. 549 and existing Rules and Regulations: JOB ADDRESSAOCATION -- _-- �, Q --- �_-__ -- CENSUS TRACT -------------------------- Owner's Name - ------ - ------- --------------- ------------------------------------ -------Phone .( -1..- Address ------------------- - - ----�grfQ-&---------- -- ---- ------- City - -------------------------------------------------------------------------- Contractor's Name 7th------------------ -------License # ------------------------ Phone ----------------- Installation will serve; Residence [] Apartment House❑ Commercial ❑Trailer•Court :F — --- j MotelC]Other -------------------------------------------- Number ------------- ----------------------------Number of living units:-_1-------- Number of'bedrooms _-01—.--Garbage Grinder ------------ lot Size ______________ Water Supply; Public System and name ___---` _ -__-T---. T_-_ Private ------------------------------------- ---------------- r 3' Character of soil to a}depth of 3 feet: Sand'[] Silt❑ Gay ❑ Peat❑ Sandy Loam ,❑ Clay Loam;❑ f Hardpan ❑ Adobe.V Fill Material ------------ If yes, type ---------------------------- �+' S (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 set wer is available within 200 feet,) a t PACKAGE TREATMENT SEPTIC TANK ['.] Size--------------; - £-------------- -----__---- Liquid Depth ----------------A-------- Capacity ; ( � t Y --------- TYh� -- ------------- Maitenal----- ------ No. Compartments -----:.-...- � .....:-•-- � F � 4;-es- -------------- -.----Foundation I--------------------- Prop. Line --------------_--•--- r` LEACHING LINE � ]; NoDis. of Lines ance nearest: Wellll ---Length of each line------------------- -------- Total Length _--_--__-_-----_--__- D' Box - _ TYP1.. Filter Material.--- ----------------Depth.Filter, Material ----------------------------------- -------- y Distance to nearest: Well ------------------- Foundation --_______--[ --------- Property Line ------------------------- SEEPAGE PIT Depth ------ - Diameter ------------ --- Number ---------------- ---------- Rock Filled Yes ❑ No 't.. r _ f Water Table Depth ------ -----i------ ------------------- --------Rock Size --- --------------------------- 1 Distance to nearest: Well -____- `'---- _ --t-- -_--_...Foundation ------------------- Prop. Line _--_----_---_ ........... F -- 'REPAIR ADDITION(Prev. Sanitation #n ' Date Pt ( pelfY fe ee }S) -----o------- - -------- � - ---- -------------- ---------- -----:----••-- -------- Disposal Field ISecY Requirements) ------- ------ - - ---Vh --------------------------------------------------------�------ ---_- -- ---- ------ - -L-------' -- -------------------------------------------------------I------------------------------------ -�------ (Draw existing and requir`ed_addition on reverse'sidel { 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 "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 ---- ---------------- ------- ------- r --------------- Owner ( t' BYtr f -- ---------------------------------- Title ------ --------- ! ! (! of er t owner) ' 1 EPAitTMENT-USE ONLY APPLICATION ACCEPTED BY --------- ------------------------------------------ DATE BUILDING PERMIT ISSUED -------------- �~ t1� ----------" - -- ---- ----------- -------- _DATE ----------------1--_------------`-------- ADDITIONAL COMMENTS �( f t�9 ----------------------- ---------------------------------------- ------------------------- --•----•- -------------------------- Final inspection by: - � - ------/------------------------------------------------------Date ---- SA., -- SA . TJOAQUIN._LOCAL HEALTH DISTRICT, E. H. 9 1-'68 Rev. 5M ..- I