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FUR OFFICE USE: APPLICATION FOR SANITATION PERMIT ....... r'.:._ . ' ....................... Permit No. (Complete In Triplicate) :.................................... . y Z_�7 This Permit Expires 1 Year From Date Issued Da ............................... te Issued . :...._•-.___... Application is hereby made to theSon Joaquin Local Health District for a permit to constrtict and install the work herein described. This application is made in compliance wlth unty Ordinance No. 549 and existing Rules and Regulations: x� JOB ADDRESS/LOCATION Y -� .. CENSUS TRACT .......................... Owner's Name .. ' _-...Phone .................................... vz,-�M Address .............. _Contractor's Name --- .... ... ............. •• ... :_..License # .� ��,e�-... Phone ........ 1 Installation will serve: Residence partment Houseo Commercial ❑Trailer Court Motel ❑Other .............. ............................ Number of living units:------1..__ Number of bedrooms ____ Garbage Grinder ----- ...... Lot Size ..... ........................ -• �I Water Supply: Public System and name .Private Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Cloy Loam ❑ Hardpan ❑ Adobe o Fill Material w. ----.._..... 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: � (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) _ PACKAGE TREATMENT [ ] SEPTIC TANXJ I Size.........-•-----•............................... Liquid Depth ..........................%Y I ' f Capacity Type .. Material...........:.......... No. Compartments Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... LEACHING LINE . [ ] No. of Lines----------------------.__. Length of each line_......................... Total length ... ...................... 'D' Box ...f. ... Type Filter Material ............... Depth .Filter Material ...............I............................ I --" •- ... Diameter ..... Foundation Property Line ........_••.........:... SEEPAGE PIT [ 3 Depth Distance fi nearest: Well ............................ Number ............................ Rock Filled Yes ❑ No Water Table Depth ............- _................................Rock Size ................... ......... Distance to nearest: Well ..............................:.........Foundation .................... Prop. Line -----.......... 1 REPAIR/ADDITION(Prev. Sonitotion Permit# ............................................ Date ............................ Septic Tank (Specify Requirements). -------------- ...... l ` .... . � .................. � ................. - .._ -�----Disp al Field ( ecify Requireents) ..._ � •-' �---.-.. .. (Draw existing and required addition on reverse side) O 1 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 Sar► Joaquin Local Health,District. Hayne 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 By ----------------------- - ----- Title ------ - f (If other than owner) i - , -F0Jt DEPARTMENT USE ONLY APPLICATION ACCEPTED BY = .......................•--- --------------- . DATE BUILDINGPERMIT ISSUED ------------ ----------•-• ...._••-------•------..-..----•-------- ----------.------------ --- __•....---DATE ------- ...:. ADDITIONALCOMMENTS ---------_-J,.- - •---------•------------------- ...................-........ ---• ----....-----.----..----------- ...-----------•-••---•-• ---.... ....... I -------------------------------------------------•----- ---- -----------------------------------1--------.-.---- ..- ----------.....-----------------------------.-........... - --•---•----------------------------- ------ '........-..:... --•-------------------------•-----••---------.......------•-•--•--............-._..-----------_.......................... . ---=........I............... --...... ......... Final Inspection b ........................................•------_-Date .....1 .......... E:H 13 24 1-68 Aev. 5M i SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M