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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT __............................... (Complete in Triplicate) Permit No. This Permit Expires 1 Year From Date Issued ' Date Issued s ,f, Application is hereby made to the San Joaquin Local Health District for a permit to construct land install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ..r--.�.. ....................CENSUS TRACT ................... Owner's Name ..... . ................. .. . ....Phone Address ,a� ... - �.1l1 . Cit • _----- - .....-- y Contractor's Name . _p.... F_---- ----- -- ----------------License # I1;Z o 3Phone Installation willserve. r Res denceXApar ment House❑ Commercial ❑Trailer Court [] `�...,�.e. Motel ❑Other .....-. .. ..... ...................... Number of living units:-. ...... Number of bedrooms ....2-.77-Garbage Grinder Lot Size .....f ._.��'� ........ Water Supply: Public System and name .... •---------- ----------- -----....__---.............------ .............................Private Character of soil to a depth of 3 feet: Sand❑—Silf E Clay 0 Peat QF_Sandy Loam (3_06y loam Q LA �1 Hardpan E] Adobe ❑ Fill Material ........ If yes,type ............................ (Plot plan, showing size ��I t, 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�, ANK Liquid Depth ...........................1 d __. ..f] [ 1 Size.....----- ....._........ , Capacity .. . Type _.._.._._ ......... Material............. ------- No. Compartments ., Distance to nearest: Well . .........I——------------ Foundation ----------- ..... Prop. Line -..._---..---- LEACHING LINE _ - . Length of each line _............. Total Length ...... 9J"D' Bax ...... Type Filter Materia{ ---------------•----Depth Filter Material -.--.---•--•-•-------•---•---.-._..._ . Distance to near s :Well -......_........._..._ Foundation Property Line ............. it k SEES PAGE P1T s\-% –,Depth: ,`! iameter ................ Number .-.._ . ..... ....__._4..... Rock Filled Yes ❑ No {] Water Table Depth ---.. Rock Size -------------•---..-•----------- i Distance to nearest: Well -7---------- ____Foundation .................... Prop. Line .._......_._._.__..:._ REPAIR/ADDITION{P a:Sanitation Permit f ----•----------------------------- Date - ---------------...-------.--._.J Septic Tank (S'ecify�equirementsl G CRr. c._ .- -.• --- --- --- -----•--ti[;� --- -F�------- d� _..- Disposal Field (Specify Requirements) -------------- --------------------------- .. ....... ..:.:.......... II --•- •-- ...................... .. .- --- -•- ------------ -- --....---._.......-- .. ....----.-. l (Drdw existing and required`ad.dition on'reverse side) �-_____ -_• hereby certify that I have prepared this application and that the work will be done in accordance with Sdh--Joaquin County Ordinances, State Laws, and Rules rind Regulations of the San Joaquin Local Health District. Home owner`oc'licen. sed agents signature certifies thelfoll wing: "I certify that in the performance of the Work for which this permit is issued,h ll'not employ'any person in such manner as to become subject to Workman's Compensation laws of California." , Signed .:..... ----•------------- Owner `Jw i � -------- ----- ------- BY Title .p. .. ...... .....e...... (If of r han owner) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDi BY .. ..... - ...._..._i DATE ..... ... ... BUILDING PERMIT ISSUED DATE . . .. ........................... .....:. ADDITIONAL COMMENTS =.._... •-----------.._---- -.,.._.--- .. .... ...... ................ ... .... z -.-* ._._._ - --- -------------------------------------------- ----------------- ------------------------------"------ -L --i----------.-............----._.............. ..- ---- --•- -....- ----•---....'--- ........................................ ... . ...._:...._...---------- --------- ------- .......Final Inspection by: .. . ................................Date .....�..�.�� ... SAN JOAQUIN LOCAL HEALTH ,DISTRICT a E. H. 3 24 1-'68 Rev. 5M .71723 H t