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FOR ©FI:icE USE: APPLICATION FOR SANITATION PERMIT ---•.............•--- •- - ---....-.:..._._.._..---..._. Permit No. __.?_�.`��..�' (Complete In Triplicate} .............. ......... p. _ _._.,.._.. This Permit Expires 1 Year From Date Issued Date Issued ._�:-� 7� 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. 649 and existing Rules and Regulations: _. JOB ADDRESS/LOCATION .... .... W.....`�(..a ........... ...................A..CENSLIS TRACT �:S s7 Owner's Name ' ?-itcc�c ....................... Phone ..,. `?� ................7.�_..... .......rr_._..... Address .`t ..... .�.._..c ...._ City ............ .. . . . . . Contractor's Name ............. .. "1------�.._._..... --- ._........---------------•License # ... Phone ................._...-• ---•-• Installation will serve: Residence 10 Apartment Houseo Commercial ❑Trailer Court Motel C]Other............... ........................ Number of living units ..... Number of bedrooms .? . Garbage-Grinder ............ Lot Size ................. .. Water Supply: Public System and name --•--------•---•--•------•-••-•.........................._.................._ ................................Private ❑ W Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ Hardpan ❑ Adobe M Fill Material ............ If yes,type....I.......... ............ (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,} �r PACKAGE TREATMENT SEPTIC TANK (f Size....-. -� ._� .�....................... Liquid Depth ..5.. ............... Capacity IMP.__..... Type ..!` __.. Material . .. No. Compartments Distance. to nearest: Well -.......----------------------------Foundation .....14-.-.:�:.... Prop. Line --- -f:0: �� r LEACHING LINE No. of Lines -------�_.. Length of each line..........:................. Total Length ._.. T....._. .. 'D' Box .....✓ Type Filter Materiai ---4.............Depth Filter Material ......./-.-$-...........I........._........ Distance to nearest: Well ---------------------- -Foundation _.- �._t`....':... Property Line -7��............... SEEPAGE PIT Depth .-.._ ......_. Diameter�. �......_ Number _...------a2_.. _.__.._., Rack Filled Yes Uf No 0 Water Table Depth ------ /.14....Rock Size Distance to nearest: Well'`.....................................:..Foundation ---- ...... Prop. Line ....:�............ ~ REPAIR/ADDITION(Prev. Sanitation Permit# ............ ............................... Date ..................... Septic Tank (Specify Requirements) ...----------------- Disposal Field (Specify Requirements) ..._-___,__ . ------------------------- ----------------------------------------- ----------------- --•------. ._........._......._...._..------....---...------••---.--.-..........._...._......---......... - (Draw existing and required addition on reverse sidel I hereby certify that 1 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 Joaquiri 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, 1 shall not employ any person In such manner as to become sable a Workman's Compensation laws of California." Signed --- Owner BY - ---------------------- `'CI - xitie %.....- -------- (if other than ed FOR -DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --- .. ..;ate ------------------- DATE. .' 5� BUILDING PERMIT ISSUED ------- -------•- •--------- -- -- -------.._._ ........ ..................................DATE .......................... ......... ADDITIONAL COMMENTS ------- ----- . .......................... _... --------------- ---------------- ------ r-_ _ `" ----------- ----------- t � _..... Final Inspection by ---- -- -- --- •.... Date -... ._ ... _4..�.? .�. .._ FH 13.2h 1`68 �v• 5M SAN JOAQUI LOCAs. HEALTH DISTRICT 3 8/7h M � c� -