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FOR OFFICE IiSE: APPLICATIION FOR SANITATION PERMIT o 7 t U Permit No. ............. IComplete in Triplicate) .._ _ , t _ .............:............... ........... •- Date Issued �......-.-.;044 � ..................................•------......_...._. This Permit Expires 1 Year from Dot*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 modelin compliance with County Ordinance No. 549 and existing Rules and Regulations: I VP JOB ADDRESS/LOCATION ................. ......................CENSUS TRACT ........,................. . - - ��- Owner's Name 1'7'4-t4--.?nf ...... ......-..-...........................Phone ...... Address � . .......:. � ... ..............City, ....... f Contractor's Name . ---------- . ...... ...... .. ..............License # .�. .��,��.yPhone,. .... Installation will serve: Residence'Q Apartment House Commercial QTraller Court ] Motel Q Other-,.-. ..... ._._.'..... a; Number of livingunits•_..J. Number of bedrooms Garbo a Grinder Lot Size .................•.......• } :--.... ` ~ _,.Private Water Supply: Public System and name ....---�--•-•-----©.......... ....................-a•_--........-,y..:.-......�..........y.... Q Character of soil to a depth of 3 feet: Sand ilt clayPeatl •--Sand Loam Clay Loam Hardpan Adobe ❑ Fill Material...=..":....If yes,type ............................ (plot plan, showing size of lot, location of system in relation to wells, buildings; etc. must ube-placed on reverse side.) NEW INSTALLATION: JNo septic tank or seepage .pit permitted if public sewer is available within 200 feet,) 4 PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size......:.................... liquid Depth Capacity Material.................... No. Compartments ..:.............. .. Type ............... Distance.to nearest: Wel! .--Foundation ........................ Prop. Line ...................... Length of each line............................ Total Length ........................... LEACHING LINE [ ] No. of Lines g Depth Filter Material D Box Type Filter Material ....--•- Distance to nearest: Well ........----------------"Foundation ........................ Property Line ........................ SEEPAGE PIT [ } Depth a Diameter ---------------- Number -_................I......... Rock Filled' Yes Q No 0 Water Table Depth ....................Rock Size ................................ - ....----- .. Distance to"nearest: Well -----------------------------•._..---...foundation .---.....-•----.---- Prop. Line .............. R a } � EPAIR/ADDITION(Prey. Sanitation Permit# _......................................:.... Date -_-._......:------..... .......... Septic Tank #Specify Requirements). -------------------------•----------------------- -----------•-••••-- ' - _,- ......................... I Disposal Field (Specify Requirements) .......... ...............:......... .3._x.4..__ ` I i��. 2. .. -------- :a-.. ; - - --••---------------- 4_ � ;P : I (Draw esting and req red addition on reverse si Ide) I hereby certify that 1 have prepared this application and that the work will be done In accordance with San 30agpin K County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health.fllstrlcF. Hems owner or Ilcen- sed agents signature ramifies the following: f "I terrify that in the performance of the work for which this permit is i:sued, I shall not employ any person in such manner as to become subject to Workman's Compensation .laws of California." i Owner Signed -------------<... - -�__..._....._._. .------- - -••- --------------....------------<- - •�- title !� -----• ... By -------------- ----- i {If other than owner[ FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY - ................... . DATE ..t/.. _, . .:. _ DATE BUILDING PERMIT ISSUED - _. :. ----- ----------------------- ----- 4 ADDITIONAL COMMENTS -----------i-------------------------------------------------................... ..... ....... ........._._..._:.--•---.._...---- ....-- . i --------------------- •---------- ------- I :_..... :.::.:._:_:........._. . �o '. ....... _. -- Final inspection by: .... -- ---- ... .....................-- ------ - Date Eli 1.3 2h 1-65 Rev. � � AN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M